Decision 2058/QD-BYT 2020 guidelines diagnosis and treatment of some common mental disorders

• Official number: 2058/QD-BYT
• Legislation Type: Decision
• Organization: The Ministry of Health
• Signer: Nguyen Truong Son
• Issued Date: 14/05/2020

MINISTRY OF HEALTH -------	SOCIALIST REPUBLIC OF VIETNAM Independence - Freedom - Happiness ---------------
No. 2058/QD-BYT	Hanoi, May 14, 2020

DECISION

INTRODUCING GUIDELINES FOR DIAGNOSIS AND TREATMENT OF SOME COMMON MENTAL DISORDERS

MINISTER OF HEALTH

Pursuant to the 2009 Law on Medical Examination and Treatment;

Pursuant to the Government’s Decree No. 75/2017/ND-CP dated June 20, 2017 on functions, duties, powers and organizational structure of the Ministry of Health;  

At the request of the Head of the Medical Service Administration,

HEREBY DECIDES:

Article 1. Promulgated together with this Decision are the guidelines for diagnosis and treatment of some common mental disorders.

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Article 3. This Decision takes effect from the date on which it is signed.

Article 4. Head of Office of the Ministry of Health; Chief Inspector of the Ministry of Health; heads of affiliates of the Ministry of Health; Directors of Departments of Health of provinces and central-affiliated cities; directors of hospitals affiliated to the Ministry of Health and heads of health units of other ministries shall implement this Decision./.

P.P. THE MINISTER
THE DEPUTY MINISTER




Nguyen Truong Son

GUIDELINES

FOR DIAGNOSIS AND TREATMENT OF SOME COMMON MENTAL DISORDERS
(Enclosed with Decision No. 2058/QD-BYT dated May 14, 2020 by Minister of Health)

CHIEF EDITOR

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CO-CHIEF EDITORS

Luong Ngoc Khue

Nguyen Doan Phuong

CONTRIBUTORS

Tran Thi Ha An

Trinh Thi Van Anh

Vu Thy Cam

Tran Manh Cuong

Nguyen Van Dung

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Le Thi Thu Ha

Tran Thi Thu Ha

Pham Cong Huan

Doan Thi Hue

Nguyen Thi Minh Huong

Vu Thi Lan

Nguyen Phuong Linh

Nguyen Thi Phuong Loan

Bui Van Loi

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Tran Nguyen Ngoc

Bui Nguyen Hong Bao Ngoc

Truong Le Van Ngoc

Bui Van San

Duong Minh Tam

Pham Xuan Thang

Le Thi Phuong Thao

Le Cong Thien

Vuong Dinh Thuy

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Ngo Van Tuat

Dang Thanh Tung

Vu Son Tung

Cao Thi Anh Tuyet

Nguyen Thi Ai Van

Ho Thu Yen

Nguyen Hoang Yen

REVIEWERS

Nguyen Thanh Binh

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Nguyen Huu Chien

Vo Thanh Dong

Le Thi Thu Ha

Do Huy Hung

Nguyen Manh Hung

Nguyen Trong Khoa

Ngo Hung Lam

Pham Van Manh

Tran Ngoc Nhan

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Dang Duy Thanh

Vuong Van Tinh

Lam Tu Trung

Lai Duc Truong

Cao Van Tuan

Nguyen Van Tuan

SECRETARIES

Dang Thanh Tung

Truong Le Van Ngoc

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TABLE OF CONTENTS

Part 1. Dementia in Alzheimer disease

Part 2. Vascular dementia

Part 3. Dementia in other diseases classified elsewhere

Part 4. Delirium, not induced by alcohol and other psychoactive substances

Part 5. Other mental disorders due to brain damage and dysfunction and to physical disease

Part 6. Personality and behavioural disorders due to brain disease, damage and dysfunction

Part 7. Mental disorders due to use of alcohol

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Part 9. Mental and behavioural disorders due to use of cannabinoids

Part 10. Mental and behavioural disorders due to use of cocaine

Part 11. Mental and behavioural disorders due to use of hallucinogens

Part 12. Mental and behavioural disorders due to multiple drug use

Part 13. Schizophrenia

Part 14. Schizotypal disorder

Part 15. Persistent delusional disorders

Part 16. Acute and transient psychotic disorders

Part 17. Mood disorders

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Part 19. Bipolar affective disorder

Part 20. Depressive episode

Part 21. Recurrent depressive disorder

Part 22. Generalized anxiety disorder

Part 23. Mixed anxiety and depressive disorder

Part 24. Dissociative disorders

Part 25. Somatoform disorders

Part 26. Anorexia

Part 27. Nonorganic insomnia

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Part 29. Autism spectrum disorder

Part 30. Attention deficit hyperactivity disorder

Part 31. Urinary incontinence

Part 32. Fecal incontinence

Part 33. Stereotypic movement disorder

Part 34. Stuttering

Part 35. Epilepsy

References.

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DEMENTIA IN ALZHEIMER DISEASE

1. DEFINITION

Alzheimer disease is a primary degenerative cerebral disease of unknown etiology with characteristic neuropathological and neurochemical features. The disorder is usually insidious in onset and develops slowly but steadily over a period of several years. Alzheimer disease begins in middle age or even earlier but the elderly are more susceptible to the disease. Alzheimer disease with onset before the age of 65-70 is commonly characterized by a family history of a similar type of dementia, a relatively faster deteriorating course and damage to the parietal lobe and temporal lobe, including aphasia or apraxia.

2. CAUSES

Macrobody: generalized cerebral atrophy with sulcal widening and fissure and ventricular enlargement.

Microbody: significant loss of neurons, especially in the hippocampus, substantia innominata, red nucleus, prefrontal cortex and temporo-parietal lobe; and appearance of neurofibrillary tangles, which are composed of paired helical filaments, and senile plaques.

 Neurochemistry: obvious decrease in acetylcholine and other neurotransmitters and neuromodulators.

3. DIAGNOSIS

3.1. Diagnosis

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a. Manifestations of impaired awareness

- Amnesia: a typical, early and prominent symptom of dementia that worsens as the disease progresses.

- Spatial disorientation: a symptom of importance to diagnosis (very obvious spatial disorientation, etc.)

- Other symptoms of impaired awareness;

+ Aphasia: may be expressive aphasia or receptive aphasia.

+ Agnosia: decrease or loss of ability to recognize common objects, people, etc. despite no damage to receptor organs.

+ Apraxia: a motor disorder despite no damage to the locomotor system.

+ Deterioration of abstract reasoning, calculation, planning, decision-making and cooperative abilities, creativity, and abilities to follow and perform complex actions.

b. Non-awareness symptoms

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20-30% of dementia patients have hallucinations Capgras syndrome

- Mood disorders: 40-50% of dementia patients experience depression and anxiety.

- Changes to personality: the patient becomes reserved, parsimonious, distrustful, unreasonably envious, childlike and/or sloppily dressed, tends to mooch, etc.

- Behavioural disorders: nighttime aggression, eating disturbance, incontinence, etc.

- Other symptoms:

+ Focal neurologic signs possibly associated with dementia

+ Sundown syndrome

+ Confusion, lashing out, falling down

c. Diagnostic criteria

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+ Symptoms persisting for at least 6 months

+ Amnesia, especially impaired ability to learn new information or to recall knowledge.

+ Other symptoms of impaired awareness (have at least one of the abovementioned symptoms).

+ Possible non-awareness symptoms

+ Presence of the abovementioned symptoms without loss of consciousness.

+ Typical symptoms of Alzheimer disease

3.1.2. Paraclinical

Possible tests:

a. Psychological tests

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- Depression assessment (Ham-D, Beck, GDS, etc.)

- Anxiety assessment (Ham-A, Zung, etc.)

- Associated sleep disorders assessment (PSQI, etc.)

- Personality tests (EPI, MMPI, etc.)

b. Complete blood count

c. Erythrocyte sedimentation rate

d. Biochemistry: liver function tests, kidney function tests, electrolyte panel test, glucose test, HbA1C test, calcium blood test, phosphorus blood test, vitamin B12 test, folate test, thyroid-stimulating hormone tests, lipid blood tests, cholinesterase tests.

e. Urine test

f. Medical imaging: cranial CT scan, cranial MRI scan, SPECT, PET, fMRI, etc. for diagnosis and differentiation from other mass lesions and cerebrovascular diseases. Abdominal cavity ultrasound and chest X-ray for detection of comorbidity or complications.

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h. Some specialized tests: syphilis test, autoantibody tests (antiphospholipid antibodies, Lupus anticoagulants, antinuclear antibodies, etc.), HIV test, genetic testing, amyloid-PET imaging, etc.

3.2. Differential diagnosis

- Depressive disorder

- Delirium

- Organic amnesia due to thyroid gland diseases, vitamin B12 deficiency

- Other types of primary dementia (such as vascular dementia, dementia in Pick disease, Lewy body dementia, dementia in Creutzfeldt - Jakob disease or Huntington disease, dementia in Parkinson disease, etc.)

- Intoxication

4. TREATMENT

4.1. Treatment rules

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4.2. Treatment regimens

- Medicinal chemistry approaches

- Psychotherapy

- Care giving

4.3. Specific treatment

4.3.1. Medicinal chemistry approaches

a. Treatment of impaired awareness: select from the following list:

Donepezil 5mg - 23mg day

Rivastigmine 1,5mg - 12mg/day (oral dosage forms and transdermal patch)

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Some drugs for treatment of impaired awareness whose effects are confirmed by research, namely neurological supplements and metabolism and cerebral circulation boosters:

Cerebrolysin 10ml - 20ml/day

Ginkgo biloba 80mg - 120mg/day

Piracetam 400mg - 1200mg/day

Citicholine 100mg - 1000mg/day

Choline alfoscerate 200mg - 800mg/day

Vinpocetine 5mg - 100mg/day

Delusions, hallucinations, depression, aggression, etc. may be treated using tranquilizers, antidepressants, anti-anxiety drugs, etc.

b. Tranquilizers

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Risperidone 1mg - 10 mg/day

Quetiapine 50mg - 800mg/day

Olanzapine 5mg - 30mg/day

Clozapine 25 - 300mg/day

Aripiprazole 10 - 30mg/day

Haloperidol 0,5 mg - 20mg/day

c. Antidepressants

Select one, two or three drugs from the following list:

Sertraline 50 - 200mg/day

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Escitalopram 10 - 20mg/day

Fluvoxamine 100 - 200mg/day

Paroxetine 20 - 50mg/day

Fluoxetine 10 - 60mg/day

Venlafaxine 75 - 375mg/day

Mirtazapine 15 - 60mg/day

d. Mood stabilizers

Select from the following list:

Sodium valproate 200mg - 2500mg/day

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Carbamazepine 100 - 1600mg/day

Oxcarbazepine 300 - 2400mg/day

Lamotrigine 100 - 300mg/day

Levitiracetam 500 - 1500mg/day

Liver supplements: aminoleban, silymarin, boganic, other branched-chain amino acids, etc.

The patient may receive dietary supplements, parenteral nutrition, etc.

4.3.2. Psychotherapy

- Direct psychotherapy: family therapy, individual therapy, etc.

- Indirect psychotherapy:

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+ Ensure a tranquil environment with no external stimuli

+ Sleep hygiene

+ Educate the patient’s family on care for the patient, etc.

4.3.3. Physical rehabilitation and occupational therapy

Physical rehabilitation and occupational therapy shall be carried out in cooperation with rehabilitation departments.

Objectives:

- Functional ability restoration

- Language therapy for language restoration

4.3.4. Treatment of associated physical diseases

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4.3.5. Social management

The patient and their caregivers should be introduced to a local dementia association to receive information and advice

Evaluate the patient’s driving ability if they wish to continue driving

Discuss care methods and services such as bathing or eating assistance at home or in accommodations ran by trained personnel with the patient and their family

4.3.6. Assistance for caregivers

Caregivers of dementia patients experience more physical and mental stress than those of the same age

Care for a dementia patient extends to both the patient and their primary caregiver

Dementia patients and their caregivers need suitable healthcare and mental support programs.

5. PROGNOSIS AND COMPLICATIONS

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Life expectancy usually ranges from 3 to 10 years following diagnosis. Alzheimer disease with early onset takes a more rapid and aggressive course. Most common causes of death are secondary diseases such as pneumonia.

6. PREVENTION

- There is no effective prophylaxis. Some preventive measures that could be taken include:

+ Avoid smoking, alcohol and stimulants.

+ Prevent and treat hypertension, high blood lipids and diabetes mellitus.

+ Eat a balanced diet that is rich in fruit and vegetables and low in sugar and saturated fats.

+ Do physical and mental exercises regularly.

Part 2

VASCULAR DEMENTIA

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Vascular dementia is a type of dementia that is caused by a scattering of ischemic strokes. Typical medical history includes temporary ischemia with a brief episode of loss of consciousness/paralysis or vision loss. Dementia may follow acute progressive strokes or, less frequently, a single massive stroke. Typical problems include disorders of higher cortical functions such as memory, reasoning, orientation, knowledge, calculation and learning abilities, language and judgment.

Vascular dementia is a consequence of cerebrovascular diseases for cognition. Vascular dementia usually starts suddenly and progresses gradually with the level of cognitive impairment depending on the location of brain damage.

2. CAUSES

- Carotid artery disease (multi-infarct dementia)

- Coronary artery disease, extracranial vascular disease and intracranial vascular disease

- Cortical ischemic strokes, subcortical ischemic strokes

- Risk factors: hypertension, diabetes mellitus, high blood cholesterol, smoking, coronary artery disease, atrial fibrillation, heart muscle disease, heart valve disease, etc.

- Small vessel disease (subcortical vascular dementia)

- Binswanger disease and lacunar infarction

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- Vascular dementia by strategic infarct (thalamus, temporal lobe, internal capsule, etc.)

- Dementia due to cerebral hemorrhage (subarachnoid hemorrhage, subdural hematoma, intracerebral hemorrhage, etc.)

- Cerebral amyloid angiopathy: cerebral hemorrhage and ischemia.

3. DIAGNOSIS

3.1. Diagnosis

3.1.1. Clinical

a. Dementia manifestations:

Amnesia and impairment of other cognitive domains affect the patient’s ability to perform activities of daily living. The patient has amnesia; impairment of at least 2 of the following cognitive domains: orientation, language, vision, attention, motor control, and motor skills; and focal neurologic signs. Understanding and judgment capacities are relatively intact.

There is a sudden onset or gradual deterioration, mood swings with temporary low mood, unprovoked crying or laughing, clouding of consciousness or delirium.

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b.  Cerebrovascular diseases

There are focal neurologic signs of stroke with or without a history of stroke. The following conditions must be ascertained by medical imaging (CT or MRI): multiple infarcts, strategic infarct (hippocampus, angular gyrus, central medial nucleus of thalamus, nucleus caudatus), lacunar infarction (multiple lacunar infarcts, basal ganglia infarction, white matter infarction); and periventricular white matter lesions.

c. Connection between dementia and cerebrovascular diseases

Dementia occurs within 3 months after stroke onset.

Pre-stroke dementia shall be excluded.

Mental ability declines suddenly.

Vascular dementia progresses in a step-wise fashion with fluctuating symptoms.

3.1.2. Paraclinical: possible tests include:

a. Psychological tests

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- Depression assessment (Ham-D, Beck, GDS, etc.)

- Anxiety assessment (Ham-A, Zung, etc.)

- Associated sleep disorders assessment (PSQI, etc.)

- Personality tests (EPI, MMPI, etc.)

b. Complete blood count

c. Erythrocyte sedimentation rate

d. Biochemistry: liver function tests, kidney function tests, electrolyte panel test, glucose test, HbA1C test, calcium blood test, phosphorus blood test, vitamin B12 test, folate test, thyroid-stimulating hormone tests, lipid blood tests.

e. Urine test

f. Medical imaging: cranial CT scan, cranial MRI scan, SPECT, PET, fMRI, etc. for diagnosis. Abdominal cavity ultrasound and chest X-ray for detection of comorbidity or complications.

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h. Some specialized tests: syphilis test, autoantibody tests (antiphospholipid antibodies, Lupus anticoagulants, antinuclear antibodies, etc.), HIV test, genetic testing, amyloid-PET imaging, etc.

3.2. Differential diagnosis

- Depressive disorder

- Delirium

- Organic amnesia due to thyroid gland diseases, vitamin b12 deficiency, chronic subdural hematoma, normal pressure hydrocephalus, etc.

- Other types of primary dementia (such as dementia in Pick disease, Lewy body dementia, dementia in Creutzfeldt - Jakob disease or Huntington disease, dementia in Parkinson disease, dementia in Alzheimer disease etc.)

- Intoxication

4. TREATMENT

4.1. General rules

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- Treat risk factors

- Pay attention to mild impaired awareness

- Employ non-pharmacological therapy

- Employ pharmacological therapy

4.2. Treatment regimens

- Pharmacological therapy

- Psychotherapy

- Care giving

4.3. Specific treatment

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a. Medicinal chemistry approaches

Treatment of impaired awareness: Select from the following list:

Donepezil 5mg - 23mg/day

Rivastigmine 1,5mg - 12mg/day (oral dosage forms or transdermal patch)

Galantamine 8mg - 24mg/day

Some drugs for treatment of impaired awareness whose effects are confirmed by research, namely neurological supplements and metabolism and cerebral circulation boosters:

Cerebrolysin 10ml - 20ml/day

Ginkgo biloba 80mg - 120mg/day

Piracetam 400mg - 1200mg/day

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Choline alfoscerate 200mg - 800mg/day

Vinpocetine 5mg - 100mg/day

Delusions, hallucinations, depression, aggression, etc. may be treated using tranquilizers, antidepressants, anti-anxiety drugs, etc.

Tranquilizers: Select one, two or three drugs from the following list:

Risperidone 1mg - 10mg/day

Quetiapine 50mg - 800mg/day

Olanzapine 5mg - 30mg/day

Clozapine 25 - 300mg/day

Aripiprazole 10 - 30mg/day

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Antidepressants: Select one, two or three drugs from the following list:

Setraline 50mg - 200mg/day

Citalopram 10mg - 40mg/day

Escitalopram 10 - 20mg/day

Fluvoxamine 100mg - 200mg/day

Paroxetine 20mg - 50mg/day

Fluoxetine 10 - 60mg/day

Venlafaxine 75 mg - 375mg/day

Mirtazapine 15mg - 45mg/day

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Sodium valproate 200mg - 2500mg/day

Divalproex sodium 750mg/day - 60mg/kg/day

Carbamazepine 100 - 1600mg/day

Oxcarbazepine 300 - 2400mg/day

Lamotrigine 100 - 300mg/day

Levetiracetam 500 - 1500mg/day

Liver supplements: aminoleban, silymarin, boganic, other branched-chain amino acids, etc.

The patient may receive dietary supplements, parenteral nutrition, etc.

b. Psychotherapy

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Indirect psychotherapy:

- Ensure a safe environment for the patient and people around the patient

- Ensure a tranquil environment with no external stimuli

- Sleep hygiene

- Educate the patient’s family on care for the patient, etc.

c. Physical rehabilitation and occupational therapy

Physical rehabilitation and occupational therapy shall be carried out in cooperation with rehabilitation departments

Objectives:

- Functional ability restoration

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Social management

The patient and their caregivers should be introduced to a local dementia association to receive information and advice

Evaluate the patient’s driving ability if they wish to continue driving

Discuss care methods and services such as bathing or eating assistance at home or in accommodations ran by trained personnel with the patient and their family

Assistance for caregivers

Caregivers of dementia patients experience more physical and mental stress than those of the same age

Care for a dementia patient extends to both the patient and their primary caregiver

Dementia patients and their caregivers need suitable healthcare and mental support programs.

4.3.2. Treatment of associated physical diseases

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Assist the patient with activities of daily living, including bathing, personal hygiene, etc. to prevent complications arising from prolonged bed rest and enhance the patient's quality of life.

5. PROGNOSIS AND COMPLICATIONS

Vascular dementia is more fatal than dementia in Alzheimer disease, which is most likely due to the presence of associated vascular diseases.

Most common causes of death for vascular dementia patients are circulatory diseases (e.g., myocardial ischemia) followed by respiratory diseases (e.g., pneumonia).

6. PREVENTION

Treatment of existing conditions such as hypertension, diabetes mellitus, high blood cholesterol, etc.

Antiplatelet drugs: aspirin, clopidogrel, ticlopidine, etc.

Carotid endarterectomy.

Part 3

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1. DEFINITION

Dementia in other diseases classified elsewhere comprises the types of dementia arising or believed to be arising from other causes besides Alzheimer disease or cerebrovascular diseases. These types of dementia can be found at any age and are quite rare in the elderly.

2. CAUSES AND TYPES

2.1. Dementia in Pick disease

2.1.1. Causes

Pick disease is caused by severe frontotemporal lobar atrophy, usually with damage to the last third of the superior temporal gyrus (language function) and localized cortical tissue lesions.

Some cases are caused by mutations in the protein tau gene on chromosome 14.

2.1.2. Diagnosis

a. Diagnosis

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This type of dementia begins in middle age (45-60 years) and is characterized by gradual personality change and decline in social interaction, leading to intellectual, memory and language impairment, apathy, euphoria and, occasionally, extrapyramidal phenomena. Dementia in Pick disease is also characterized by selective frontotemporal lobar degeneration without senile plaques or neurofibrillary tangles as seen in normal aging. Early onset cases usually have a more malignant course with social and behavioural manifestations preceding actual memory impairment.

Manifestations are clearer in the frontal lobe than in the temporal or parietal lobe, unlike Alzheimer disease.

Paraclinical: possible tests include:

- Psychological tests:

+ Cognition assessment (MMSE, GPCOG, Mini-Cog, ADAS-Cog, Wechsler, etc.)

+ Depression assessment (Ham-D, Beck, GDS, etc.)

+ Anxiety assessment (Ham-A, Zung, etc.)

+ Associated sleep disorders assessment (PSQI, etc.)

+ Personality tests (EPI, MMPI, etc.)

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- Erythrocyte sedimentation rate

- Biochemistry: liver function tests, kidney function tests, electrolyte panel test, glucose test, HbA1C test, calcium blood test, phosphorus blood test, vitamin B12 test, folate test, thyroid-stimulating hormone tests, lipid blood tests.

- Urine test

- Medical imaging: cranial CT scan, cranial MRI scan, SPECT, PET, fMRI, etc. for lesion evaluation. Abdominal cavity ultrasound and chest X-ray for detection of comorbidity or complications.

- Functional diagnostics: EEG, cerebral blood flow, ECG, transcranial Doppler ultrasound, etc.

- Some specialized tests: syphilis test, autoantibody tests (antiphospholipid antibodies, Lupus anticoagulants, antinuclear antibodies, etc.), HIV test, genetic testing, amyloid-PET imaging, FDG-PET scan, brain biopsy, etc.

b. Differential diagnosis

Dementia in Alzheimer disease; vascular dementia; secondary dementia due to other diseases such as neurosyphilis; normal pressure hydrocephalus, other metabolic and mental disorders.

2.2. Dementia in Creutzfeldt-Jacob disease

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Multiple viruses might have combined to transmit the disease.

2.2.2. Diagnosis

a. Diagnosis

Clinical

A progressive dementia with extensive neurological signs, due to specific neuropathological changes (subacute encephalomalacia) that are presumed to be caused by a transmissible agent.

Onset is usually in middle or later life, typically at 50 years of age. Progression is relatively rapid within several months or 1-2 years.

There is usually progressive spastic paralysis of the limbs, accompanied by  extrapyramidal signs with tremor, rigidity and choreoathetoid movements chorea. Other possible symptoms include ataxia, visual failure, or muscle fibrillations and atrophy of the upper motor neurons.

 3 typical symptoms include severe and rapidly progressive dementia, pyramidal and extrapyramidal disorders and fasciculations. EEG pattern (triphasic waves) is characteristic of the disease.

Note: rapid progression and early motor disorders are valuable diagnostic hints

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- Psychological tests

+ Cognition assessment (MMSE, GPCOG, Mini-Cog, ADAS-Cog, Wechsler, etc.)

+ Depression assessment (Ham-D, Beck, GDS, etc.)

+ Anxiety assessment (Ham-A, Zung, etc.)

+ Associated sleep disorders assessment (PSQI, etc.)

+ Personality tests (EPI, MMPI, etc.)

- Complete blood count

- Erythrocyte sedimentation rate

- Biochemistry: liver function tests, kidney function tests, electrolyte panel test, glucose test, HbA1C test, calcium blood test, phosphorus blood test, vitamin b12 test, folate test, thyroid-stimulating hormone tests, lipid blood tests, etc.

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- Medical imaging: cranial CT scan, cranial MRI scan, SPECT, PET, fMRI, etc. Abdominal cavity ultrasound and chest X-ray for detection of comorbidity or complications.

- Cerebrospinal fluid analysis: protein (protein Tau > 1200 picograms/mL), enolase increase

- Functional diagnostics: EEG, cerebral blood flow, ECG, transcranial Doppler ultrasound, etc.

- Some specialized tests: syphilis test, autoantibody tests (antiphospholipid antibodies, Lupus anticoagulants, antinuclear antibodies, etc.), HIV test, genetic testing, amyloid-PET imaging, FDG-PET scan, brain biopsy, etc. for suspected cases

b. Differential diagnosis

- Alzheimer disease

- Pick disease

- Parkinson disease

- Post-encephalitic Parkinsonism

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2.3.1. Cause

The disorder is transmitted by a single autosomal dominant gene.

2.3.2. Diagnosis

a. Diagnosis

Clinical

This type of dementia occurs as a result of generalized brain atrophy. Typical symptoms appear at 30-40 years of age. Earliest symptoms include apparent presence of delusion, depression or anxiety and personality change.

Progression is slow. Death occurs within 10-15 years.

Uncontrollable movements, typically on the face, by the hands and shoulders or in walking posture, are early signs and usually precede amnesia.

This type of dementia is characterized by frontal lobe dysfunction in early stages and relative memory retention as the disease takes its course.

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Paraclinical

All tests for the abovementioned dementia types may be conducted.

b. Differential diagnosis

Other cases of movement disorders; Alzheimer disease; Pick disease; Creutzfeldt - Jacob disease.

2.4. Dementia in Parkinson disease

2.4.1. Cause

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 Injury to dopaminergic neurons of the nigrostriatal pathways with involvement of genetic factors.

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a. Diagnosis

Clinical

Dementia emerges as Parkinson disease progresses and is usually severe.

¾ of elderly Parkinson patients develop dementia within 10 years.

Clinical characteristics include cognitive and motor impairment, amnesia, decline in cognitive skills, visual illusions, depression, impaired concentration and judgment and sleep disorders.

Cognitive symptoms usually appear at least 1 year after Parkinson disease is diagnosed.

Paraclinical

All tests for the abovementioned dementia types shall be conducted.

b. Differential diagnosis

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2.5. Dementia in human immunodeficiency virus [HIV] disease

2.5.1. Cause

The disease is caused by HIV through an unclear mechanism.

2.5.2. Diagnosis

a. Diagnosis

Clinical

Typical manifestations of dementia in HIV disease include forgetfulness, impaired flexibility, poor concentration and difficulty in reading and resolving problems. It is common for the patient to appear apathetic and suffer from mental slowness and/or social isolation. Some atypical manifestations are mood disorders, psychotic disorders or seizures. Physical examination shows tremor, dysdiadochokinesia, loss of balance, ataxia, hypotonia, generalized hyperreflexia, frontal release signs, impaired eye tracking performance and nystagmus.

The disease progresses rapidly (weeks or months) and leads to severe total dementia, loss of speech and death.

Paraclinical: possible tests include:

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- Complete blood count

- Erythrocyte sedimentation rate

- Biochemistry: liver function tests, kidney function tests, electrolyte panel test, glucose test, HbA1C test, calcium blood test, phosphorus blood test, vitamin B12 test, folate test, thyroid-stimulating hormone tests, lipid blood tests.

- Urine test

- Medical imaging: cranial CT scan, cranial MRI scan, SPECT, PET, fMRI, etc. for lesion evaluation. Abdominal cavity ultrasound and chest X-ray for detection of comorbidity or complications.

- Functional diagnostics: EEG, cerebral blood flow, ECG, transcranial Doppler ultrasound, etc.

- Psychological tests

+ Cognition assessment (MMSE, GPCOG, Mini-Cog, ADAS-Cog, Wechsler, etc.)

+ Depression assessment (Ham-D, Beck, GDS, etc.)

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+ Associated sleep disorders assessment (PSQI, etc.)

+ Personality tests (EPI, MMPI, etc.)

- Some specialized tests: syphilis test, autoantibody tests (antiphospholipid antibodies, Lupus anticoagulants, antinuclear antibodies, etc.), HIV test, genetic testing, amyloid-PET imaging, FDG-PET scan, brain biopsy, etc. for suspected cases

- Differential diagnosis

+ Dementia in Alzheimer disease

+ Vascular dementia

+ Pick disease

+ Creutzfeldt-Jakob disease

+ Metabolic diseases and other types of dementia.

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Dementia may occur as a manifestation or result of different physical or brain diseases, namely:

- Carbon monoxide intoxication

- Cerebral sphingolipidoses

- Epilepsy

- Complete paralysis in psychotic disorders

- Wilson disease

- Hypercalcaemia

- Acquired hypothyroidism

- Intoxication

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- Neurosyphilis

- Pellagra

- Multiple arterial thrombosis

- Systemic lupus erythematosus

- African trypanosomiasis

- Vitamin B12 deficiency

3. TREATMENT

3.1. General rules

- These types of dementia are curable and require appropriate treatments.

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- The patient’s family and doctors shall cooperate in providing care for the patient at home.

3.2. Treatment regimens

- Pharmacological therapy

- Psychotherapy

- Care giving

3.3. Specific treatment

a. Medicinal chemistry approaches

Treatment of impaired awareness: Select from the following list:

Donepezil 5mg - 23mg/day

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Galantamine 8mg - 24mg/day

Neuroprotective agents:

Cerebrolysin 10ml - 20ml/day during acute period

Ginkgo biloba 80mg - 120mg/day

Piracetam 400mg - 1200mg/day

Citicholine 100mg - 1000mg/day

Choline alfoscerate 200mg - 800mg/day

Vinpocetine 5mg - 100mg/day

Nicergoline 10mg - 30mg/day

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Other disorders such as delusions, hallucinations, depression, aggression, etc. may be treated using tranquilizers, antidepressants, anti-anxiety drugs, etc.

Tranquilizers: Select one, two or three drugs from the following list:

Risperidone 1mg - 10mg/day

Quetiapine 50mg - 800mg/day

Olanzapine 5mg - 30mg/day

Clozapine 25 - 300mg/day

Aripiprazole 10 - 30mg/day

Haloperidol 0,5 mg - 20mg/day

Antidepressants: Select one, two or three drugs from the following list:

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Citalopram 10mg - 40mg/day

Escitalopram 10 - 20mg/day

Fluvoxamine 100mg - 200mg/day

Paroxetine 20mg - 50mg/day

Fluoxetine 10 - 60mg/day

Venlafaxine 75 mg - 375mg/day

Mirtazapine 15mg - 45mg day

Mood stabilizers: Select from the following list:

Sodium valproate 200mg - 2500mg/day

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Carbamazepine 100 - 1600mg/day

Oxcarbazepine 300 - 2400mg/day

Lamotrigine 100 - 300mg/day

Levetiracetam 500 - 1500mg/day

Liver supplements: aminoleban, silymarin, boganic, other branched-chain amino acids.

The patient may receive dietary supplements, parenteral nutrition, etc.

b. Psychotherapy

- Direct psychotherapy: family therapy, individual therapy, etc.

- Indirect psychotherapy:

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+ Ensure a tranquil environment with no external stimuli

+ Sleep hygiene

+ Educate the patient’s family on care for the patient, etc.

c. Physical rehabilitation and occupational therapy

Physical rehabilitation and occupational therapy shall be carried out in cooperation with rehabilitation departments

Objectives:

- Functional ability restoration

- Language therapy for language restoration

d. Social management

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Evaluate the patient’s driving ability if they wish to continue driving

Discuss care methods and services such as bathing or eating assistance at home or in accommodations ran by trained personnel with the patient and their family

e. Assistance for caregivers

Caregivers of dementia patients experience more physical and mental stress than those of the same age

Care for a dementia patient extends to both the patient and their primary caregiver

Dementia patients and their caregivers need suitable healthcare and mental support programs.

f. Treatment of associated physical diseases

Use antiplatelet drugs for atherosclerosis. If there is carotid artery stenosis, perform angioplasty and stent placement. If there is hypertension, lower blood pressure. If there are high blood lipids, use statins, fibrates, nicotinic acid, cholesterol absorption inhibitors). If there is diabetes, use lipid-regulating drugs, etc.

Assist the patient with activities of daily living, including bathing, personal hygiene, etc. to prevent complications arising from prolonged bed rest and enhance the patient's quality of life.

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Prognosis and complications are different for each type of dementia:

For dementia in Pick disease: the disease progresses slowly but eventually leads to severe brain damage. The patient becomes dependent on other people for activities of daily living. Leading cause of death is pneumonia. Life expectancy is 7 to 10 years.

For dementia in Creutzfeldt-Jacob disease: the disease takes a rapid course and quickly leads to death. Life expectancy is 1 to 2 years.

For dementia in Huntington disease: the disease progresses slowly. Life expectancy is 10 to 25 years following diagnosis. Causes of death are usually pneumonia and cardiovascular diseases.

For dementia in Parkinson disease: the disease progresses faster than Alzheimer disease. Leading causes of death are diseases associated with prolonged immobility, poor nutrition and difficulty in swallowing.

Dementia in HIV disease: the disease progresses rapidly and can lead to death within several months if not treated.

5. PREVENTION

Avoid smoking, alcohol and stimulants.

Prevent and treat hypertension, high blood lipids and diabetes mellitus.

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DELIRIUM, NOT INDUCED BY ALCOHOL AND OTHER PSYCHOACTIVE SUBSTANCES

1. DEFINITION

Delirium, also known as acute confusional state, acute brain syndrome, metabolic encephalopathy, alcohol-induced psychotic disorder, etc., is a syndrome characterized by the presence of disturbed consciousness (i.e., reduced clarity of awareness of the environment and reduced ability to focus and sustain or shift attention) according to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD 10) and the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-4).

2. CAUSES

Besides alcohol and other psychoactive substances, delirium can be induced by the following causes:

- Traumatic brain injury, brain tumors, epidural hematoma, abscesses, intracranial hematoma, brain hemorrhage, nonhemorrhagic stroke, temporary anemia, etc.

- Metabolic disorders, electrolyte imbalances, etc.

- Diabetes mellitus, hypoglycemia, hyperglycemia or insulin resistance

- Infection (septicemia, malaria, viral infection, bubonic plague, syphilis, abscesses, etc.)

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- Neuroleptic malignant syndrome, serotonin syndrome, etc.

- Severe physical diseases such as hepatitis, renal failure, heart failure, etc.

- Malnutrition, etc.

3. DIAGNOSIS

3.1. Clinical

Characteristics

Delirium can occur at any age and is more common in people in their 60s.

The syndrome is characterized by concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behavior, emotion and the sleep-wake schedule.

Most cases recover within 4 weeks or less.

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Impairment of consciousness and attention (on a continuum from clouding to coma; reduced ability to direct, focus, sustain, and shift attention)

Global disturbance of cognition (e.g., perceptual distortions, illusions and hallucinations-most often visual; impairment of abstract thinking and comprehension, with or without transient delusions, but typically with some degree of incoherence; impairment of immediate recall and of recent memory but with relatively intact remote memory; disorientation for time as well as, in more severe cases, for place and person)

Psychomotor disturbances (e.g., hypo- or hyperactivity and unpredictable shifts from one to the other; increased reaction time; increased or decreased flow of speech; enhanced startle reaction)

Disturbance of the sleep-wake cycle (e.g., insomnia or, in severe cases, total sleep loss or reversal of the sleep-wake cycle; daytime drowsiness; nocturnal worsening of symptoms; disturbing dreams or nightmares)

Emotional disturbance (e.g., depression, anxiety or fear, irritability, euphoria, apathy, or wondering perplexity)

The onset is usually rapid, the course diurnally fluctuating, and the total duration of the condition less than six months. The above clinical picture is so characteristic that a fairly confident diagnosis of delirium can be made even if the underlying cause is not clearly established. In addition to a history of an underlying physical or brain disease, evidence of cerebral dysfunction (e.g., an abnormal EEG, usually but not invariably showing a slowing of the background activity) may be required if the diagnosis is in doubt.

3.2. Paraclinical: possible tests include:

- Blood tests: complete blood count, biochemical blood test (electrolyte panel, kidney and liver function tests, thyroid function tests, glucose, D-dimer, ACTH stimulation test, etc.)

- Arterial blood gas test for detection of low blood oxygen level and high CO2 and lactate levels.

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- Functional diagnostics: EEG, cerebral blood flow, ECG, transcranial Doppler ultrasound, etc.

- Medical imaging: CT-Scanner, cranial MRI,  abdominal ultrasound, abdominal X-ray, chest X-ray, etc.

- Toxin blood tests for digoxin, lithium, quinidine, alcohol, narcotic substances, etc.

- Cerebrospinal fluid analysis for detection of encephalitis and meningitis

- Syphilis tests, HIV tests.

- Other indicated tests.

ICD 10 diagnostic criteria

A. Clouding of consciousness, attention alteration

B. Disturbance of cognition with both of the following symptoms:

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2) Disorientation for place, time or person

C. At least one of the following psychomotor disturbances:

1) Hypo- or hyperactivity and unpredictable shifts from one to the other

2) Increased reaction time

3) Increased or decreased flow of speech

4) Enhanced startle reaction

D. Disturbance of the sleep-wake cycle with at least one of the following symptoms:

1) insomnia or, in more severe cases, total sleep loss or reversal of the sleep-wake cycle, daytime drowsiness;

2) Nocturnal worsening of symptoms,

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E. Rapid symptom onset with diurnally fluctuating course

F. In addition to a history of an underlying physical or brain disease, evidence of cerebral dysfunction (e.g., an abnormal EEG, usually but not invariably showing a slowing of the background activity) may be required if the diagnosis is in doubt

3.3. Differential diagnosis

- Dementia and delirium are differentiated based on clinical symptoms. Delirium onset is sudden while  dementia is usually associated with an insidious onset. Cognitive change in dementia is stable over time and does not fluctuate diurnally. In dementia, consciousness remains intact whereas there are bouts of cognitive decline/disturbance in delirium. Attention shall be paid to delirium superimposed on dementia.

- For schizophrenia or depression/mania: schizophrenia is associated with relatively more stable and systematic hallucinations and delusions and not associated with cognitive disorders or disorientation. Hypoactive delirium and depression are differentiated based on clinical symptoms and EEG. However, schizophrenia, depression and mania can predispose to delirium, either through self-neglect or exhaustion, or because of the strong psychotropic drugs used to treat them.

- Physical diseases: ischemic stroke, myocardial infarction, acute infection, hyperglycemia/hypoglycemia, hypoxemia, hypercapnia, acute urinary tract obstruction, substance/drug-induced disorders, hepatic encephalopathy, renal failure, hypernatremia/hyponatremia, hypocalcemia, encephalitis-meningitis, brain tumor, effects of stroke, constipation, effects of brain injury, Addison disease, thyrotoxicosis, myxedema coma, brain abscess, neurosyphilis, Wernicke disease.

4. TREATMENT

4.1. Rules

- Delirium cause treatment: detection and treatment of delirium causes are crucial.

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- Medicinal chemistry: take medicinal chemistry approaches for disorder symptoms. Prescribe doses lower than the common dose and use the lowest effective dose for the shortest possible duration of time.

4.2. Treatment regimens

- Cause treatment

- Delirium symptom treatment

- Patient care and management

4.3. Specific treatment

4.3.1. Medicinal chemistry approaches

a. Tranquilizers: Select one, two or three drugs from the following list:

Haloperidol: 5mg - 20 mg/day

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Clozapine: 25mg - 300mg/day

Olanzapine: 5mg - 30mg/day

Quetiapine: 50mg - 800mg/day

Aripiprazole: 10 - 30mg/day

For patients with Parkinson disease or Lewy body dementia, select tranquilizers that do not worsen Parkinson’s symptoms (clozapine or quetiapine) and avoid haloperidol.

Insomnia responds well to short or medium half-life benzodiazepines (e.g., lorazepam, zopiclone). Avoid long half-life drugs and barbiturates.

Care and support are essential to the patient. Underlying disorders and delirium cause(s) need to be addressed to minimize risks as well as improving  the patient’s condition.

As delirium mostly affects the elderly, delirium care can reduce complications arising such as urinary incontinence, immobility, falling, pressure ulcers, dehydration, malnutrition, etc.

Cognitive enhancers: Select from the following list:

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Rivastigmine: 1,5mg - 12mg/day (oral dosage forms or transdermal patch)

Galantamine: 8mg - 24mg/day and other drugs.

Neuroprotective agents: Select one, two or three drugs from the following list:

Cerebrolysin 10ml - 20ml/day

Ginkgo biloba 80mg - 120mg/day

Piracetam 400mg - 1200mg/day

Citicholine 100mg - 1000mg/day

Choline alfoscerate 200mg - 800mg/day

Vinpocetine 5mg - 100mg/day

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Antioxidants: vitamin E, selegiline.

Liver supplements: aminoleban, silymarin, boganic, other branched-chain amino acids, etc.

The patient may receive dietary supplements, parenteral nutrition, etc.

4.3.2. Psychotherapy

- Direct psychotherapy: family therapy, individual therapy, etc.

- Indirect psychotherapy:

+ Ensure a safe environment for the patient and people around the patient

+ Ensure a tranquil environment with no external stimuli

+ Sleep hygiene

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4.3.3. Physical rehabilitation and occupational therapy

4.3.4. Treatment of associated physical diseases or underlying causes

- Drug use

- Infection, metabolic disorders

- Cerebral hypoxia (anemia, heart failure, COPD, etc.) and other conditions.

4.3.5. Rehabilitation

Assess activities of daily living regularly

Create a comfortable environment with habits and regular reminders of date, time and place.

The patient’s family needs to be involved in this process to care for and support the patient.

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5. PROGNOSIS AND COMPLICATIONS

5.1. Prognosis

Symptoms usually persist until the cause(s) is/are resolved. Delirium usually lasts less than a week.

The older a patient is, the poorer the prognosis is.

5.2. Complications

Complications related to underlying conditions

Infection and injuries, which must be monitored and controlled

6. PREVENTION

Provide sufficient care for severe physical diseases to prevent delirium (environmental conditions, safe and quiet space with adequate lighting)

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OTHER MENTAL DISORDERS DUE TO BRAIN DAMAGE AND DYSFUNCTION AND TO PHYSICAL DISEASE

1. DEFINITION

Organic mental disorders are mental disorders directly related to brain damage due to cerebral diseases (brain tumors, encephalitis, atrophy, etc.) or non-cerebral diseases (internal medicine diseases, endocrine disorders, infection, intoxication, metabolic disorders, etc.) that affect cerebral functions.

Organic mental disorders involve all other clinical departments, showing the relation between the physical and the mental.

Organic mental disorders are listed under F00 – F09 in the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD 10), in which, other mental disorders due to physical causes are coded F06 and comprise syndromes of which the most conspicuous manifestations are in the areas of perception (hallucinations), thought contents (delusions), or mood and emotion (depression, elation, anxiety), as well as cognitive disorders, etc.

2. CAUSES

2.1. Cerebral causes

- Brain tumors

- Brain abscesses, meningitis, encephalitis, HIV, syphilis

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- Parkinson disease, Huntington disease

- Strokes: brain hemorrhage, subarachnoid hemorrhage, ischemic stroke, etc.

2.2. Non-cerebral diseases affecting cerebral functions

- Infection: septicemia, urinary tract infection, pneumonia, etc.

- Anemia, electrolyte disorders, renal failure or liver failure, hypoglycemia or hyperglycemia, post-operative disease

- Endocrine system: thyroid disorders or glucocorticoid disorders (overdose), etc.

- Nutrition: Vitamin B12, folate deficiency, etc.

3. DIAGNOSIS

3.1. Clinical

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Evidence of cerebral disease, damage or dysfunction, or of systemic physical disease, known to be associated with one of the listed syndromes

A temporal relationship (weeks or a few months) between the development of the underlying disease and the onset of the mental syndrome

Recovery from the mental disorder following removal or improvement of the underlying presumed cause

Absence of evidence to suggest an alternative cause of the mental syndrome (such as a strong family history or precipitating stress).

3.2. Paraclinical: possible tests include:

- Blood tests: complete blood count, biochemical blood test (electrolyte panel, kidney and liver function tests, thyroid function tests, glucose, D-dimer, ACTH stimulation test, etc.)

- Arterial blood gas test for detection of low blood oxygen level and high CO2 and lactate levels.

- Urine test

- Functional diagnostics: EEG, cerebral blood flow, ECG, transcranial Doppler ultrasound, etc.

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- Toxin blood tests for digoxin, lithium, quinidine, alcohol, narcotic substances, etc.

- Cerebrospinal fluid analysis for detection of encephalitis and meningitis

- Syphilis tests, HIV tests.

- Other indicated tests.

Ensure the general criteria in the introduction to F06 above are met. Organic mental disorders are classified as follows:

1) Organic hallucinosis (F06.0)

A disorder of persistent or recurrent hallucinations, usually visual or auditory, that occur in clear consciousness and may or may not be recognized by the patient as such. Delusional elaboration of the hallucinations may occur.

In addition to the general criteria in the introduction to F06 above, there should be no clouding of consciousness; no significant intellectual decline; no predominant disturbance of mood; and no predominance of delusions.

2) Organic catatonic disorder (F06.1.)

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In addition to the general criteria in the introduction to F06 above, there should be:

Stupor (diminution or complete absence of spontaneous movement with partial or complete mutism, negativism, and rigid posturing)

Excitement (gross hypermotility with or without a tendency to assaultiveness)

Both (shifting rapidly and unpredictably from hypo- to hyperactivity)

Other catatonic phenomena that increase confidence in the diagnosis are: stereotypies, waxy flexibility, and impulsive acts.

3) Organic delusional [schizophrenia-like] disorder (F06.2.)

A disorder in which persistent or recurrent delusions dominate the clinical picture.

In addition to the general criteria in the introduction to F06 above, there should be delusions (persecutory, of bodily change, jealousy, disease, or death of the patient or another person).

Includes: paranoid and paranoid-hallucinatory organic states

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4) Organic mood disorders (F06.3.)

Disorders characterized by a change in mood or affect, usually accompanied by a change in the overall level of activity. The affective disorder must follow the presumed organic factor and be judged not to represent an emotional response to the patient's knowledge of having, or having the symptoms of, a concurrent brain disorder.

Postinfective depression (e.g. following influenza) is a common example and should be coded here. Persistent mild euphoria not amounting to hypomania (which is sometimes seen, for instance, in association with steroid therapy or antidepressants) should not be coded here but under F06.8.

In addition to the general criteria for assuming organic etiology, laid down in the introduction to F06, the condition must meet the requirements for a diagnosis of one of the disorders listed under F30-F33.

The following five-character codes might be used to specify the clinical disorder:

F06.30 Organic manic disorder

F06.31 Organic bipolar affective disorder

F06.32 Organic depressive disorder

F06.33 Organic mixed affective disorder

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Organic anxiety disorder (F06.4.)

A disorder characterized by the essential descriptive features of a generalized anxiety disorder (F41.1), a panic disorder (F41.0), or a combination of both, but arising as a consequence of an organic disorder capable of causing cerebral dysfunction (e.g. temporal lobe epilepsy, thyrotoxicosis, or phaechromocytoma).

Organic dissociative disorder (F06.5.)

A disorder that meets the requirements for one of the disorders in F44. - (dissociative disorder) and for which the general criteria for organic etiology are also fulfilled (as described in F06).

Organic emotionally labile [asthenic] disorder (F06.6.)

A disorder characterized by marked and persistent emotional incontinence or lability, fatiguability, or a variety of unpleasant physical sensations (e.g. dizziness) and pains regarded as being due to the presence of an organic disorder. This disorder is thought to occur in association with cerebrovascular disease or hypertension more often than with other causes.

Mild cognitive disorder (F06.7.)

The main feature is a decline in cognitive performance. This may include memory impairment, learning or concentration difficulties. Objective tests usually indicate abnormality. The symptoms are such that a diagnosis of dementia (F00-F03), organic amnesic syndrome (F04) or delirium (F05.-) cannot be made.

Other specified mental disorders due to brain damage and dysfunction and to physical disease (F06.8.)

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Unspecified mental disorder due to brain damage and dysfunction and to physical disease (F06.9.)

4. TREATMENT

4.1. Treatment rules

Treatment mainly involves treatment of causes of the mental disorders, namely cerebral disorders or non-cerebral diseases affecting cerebral functions

Besides treating causes and symptoms of mental disorders, take care of the patient and improve the patient’s condition and immunity to facilitate recovery.

4.2. Treatment regimens for each type of disorder

Hallucinations/delusions: select one, two or three drug(s) from the following list:

Risperidone 1mg - 10mg/day

Quetiapine 50mg - 800mg/day

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Clozapine 25 - 300mg/day

Aripiprazole 10 - 30mg/day

Haloperidol 0,5 mg - 20mg/day

Depressive/anxiety disorders: select one, two or three drug(s) from the following list:

Amitriptyline 25 - 150mg/day

Sertraline 50mg - 200mg/day

Citalopram 10mg - 40mg/day

Escitalopram 10 - 20mg/day

Fluvoxamine 100mg - 300mg/day

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Fluoxetine 10 - 60mg/day

Venlafaxine 75 mg - 375mg/day

Mirtazapine 15mg - 45mg/day

Anti-anxiety drugs (if necessary):

Diazepam 5 - 20mg/day

Bromazepam 2 - 6mg/day

Zopiclone, zolpidem, zaleplon, etc.

Severe depression: combine antidepressants with tranquilizers

Mood instability: select from the following list:

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Divalproex sodium 750mg/day - 60mg/kg/day

Carbamazepine 100 - 1600mg/day

Oxcarbazepine 300 - 2400mg/day

Lamotrigine 100 - 300mg/day

Levetiracetam 500 - 1500mg/day

Impaired awareness: Select from the following list:

Donepezil 5mg - 23mg/day

Rivastigmine 1,5mg - 12mg/day (oral dosage forms or transdermal patch)

Galantamine 8mg - 24mg/day

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Cerebrolysin 10ml - 20ml/day during acute period

Ginkgo biloba 80mg - 120mg/day

Piracetam 400mg - 1200mg/day

Citicholine 100mg - 1000mg/day

Choline alfoscerate 200mg - 800mg/day

Vinpocetine 5mg - 100mg/day

Vitamin supplements:

High dose of vitamin B1: 500 -1000 mg

Vitamin B12: 500 -1000mcg

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Vitamin PP: 300mg; and other supplements

Liver supplements: aminoleban, silymarin, boganic, other branched-chain amino acids, etc.

The patient may receive dietary supplements, parenteral nutrition, etc.

Psychotherapy

- Direct psychotherapy: family therapy, individual therapy, etc.

- Indirect psychotherapy:

+ Ensure a safe environment for the patient and people around the patient

+ Ensure a tranquil environment with no external stimuli

+ Sleep hygiene

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Physical rehabilitation and occupational therapy

5. PROGNOSIS AND COMPLICATIONS

5.1. Prognosis

Symptoms usually persist until their causes are resolved. Mental disorders will diminish or disappear when their physical causes are resolved.

A patient with multiple physical diseases or severe brain damage/physical diseases will have poorer prognosis.

5.2. Complications

Complications related to underlying conditions

Infection and injuries, which must be monitored and controlled

Personality and behavioural changes caused by prolonged illness

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6. PREVENTION

As organic mental disorders are mostly caused by cerebral and non-cerebral diseases, it is essential to improve health via exercise, nutrition, appropriate occupational hygiene and healthy lifestyle.

Prevent and promptly treat physical diseases, and promptly detect and treat mental disorders in specialized establishments.

Part 6

PERSONALITY AND BEHAVIOURAL DISORDERS DUE TO BRAIN DISEASE, DAMAGE AND DYSFUNCTION

1. DEFINITION

Alteration of personality and behavior can be a residual or concomitant disorder of brain disease, damage, or dysfunction.

Personality change means that the patient’s fundamental means of interacting and behaving have been altered. When a true personality change occurs in adulthood, brain injury should be suspected.

2. CAUSES

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Traumatic brain injury, a common cause

Frontal lobe tumors such as gliomas

Progressive dementias, especially symptoms of atrophy, such as vascular dementia, dementia in HIV, dementia in Huntington disease, white matter atrophy, etc.

Exposure to toxic substances, such as radiation, which can also lead to significant personality change.

3. DIAGNOSIS

3.1. Clinical

These disorders are characterized by a significant alteration of the habitual patterns of premorbid behavior. The expression of emotions, needs, and impulses is particularly affected.

Cognitive functions may be defective mainly or even exclusively in the areas of planning and anticipating the likely personal and social consequences, as in the so-called frontal lobe syndrome. However, it is now known that this syndrome occurs not only with frontal lobe lesions but also with lesions to other circumscribed areas of the brain.

In terms of behaviors, main symptoms involve depression, enhanced impulsiveness and enhanced aggressiveness, which may lead to substance abuse, transgression, etc.

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Laboratory tests, medical imaging and psychological tests can support detection of underlying causes, differential diagnosis, monitoring, treatment and prognosis.

Basic laboratory tests

Blood tests: hematological tests, liver function tests, kidney function tests, electrolyte panel, CPK test, etc. 

Urine test

Tests for narcotic substances

Serological testing for syphilis, HIV

Cerebrospinal fluid analysis and other tests

Medical imaging, functional diagnostics: chest X-ray, abdominal ultrasound, etc.

EEG, ECG, cerebral blood flow, transcranial Doppler ultrasound, etc.

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Psychological tests:

Personality tests: EPI, MMPI

Mood assessment: anxiety (Zung, Ham- A, etc.), depression (Beck, Ham-D, etc.)

Diagnostic criteria of F07

G1. Objective evidence (from physical and neurological examination and laboratory tests) and/or history, of cerebral disease, damage, or dysfunction

G2. Absence of clouding of consciousness and of significant memory deficit

G3. Absence of sufficient or suggestive evidence for an alternative causation of the personality or behavior disorder that would justify its placement in F60-F69

1) Organic personality disorder (F07.0)

- This disorder is characterized by a significant alteration of the habitual patterns of premorbid behavior. The expression of emotions, needs, and impulses is particularly affected.

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- Consistently reduced ability to persevere with goal-directed activities

Altered emotional behavior, characterized by emotional lability, shallow and unwarranted cheerfulness (euphoria, inappropriate jocularity), and easy change to irritability or short-lived outbursts of anger and aggression; in some instances apathy may be a more prominent feature.

- Expression of needs and impulses without consideration of consequences or social convention (the patient may engage in dissocial acts, such as stealing, inappropriate sexual advances, or voracious eating, or may exhibit disregard for personal hygiene)

- Cognitive disturbances, in the form of suspiciousness or paranoid ideation, and/or excessive preoccupation with a single, usually abstract, theme (e.g. religion, "right" and "wrong")

- Marked alteration of the rate and flow of language production, with features such as circumstantiality, over-inclusiveness, viscosity, and hypergraphia.

- Altered sexual behavior (hyposexuality or change of sexual preference).

Includes:

+ Frontal lobe syndrome

+ Limbic epilepsy personality syndrome

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+ Organic pseudopsychopathic personality

+ Organic pseudoretarded personality

+ Postleucotomy syndrome

2) Post-encephalitic syndrome (F07.1)

- The syndrome includes residual behavioural change following recovery from either viral or bacterial encephalitis. Symptoms are nonspecific and vary from individual to individual, from one infectious agent to another, and, most consistently, with the age of the individual at the time of infection

- The principal difference between this disorder and the organic personality disorders is that it is often reversible.

- The manifestations may include general malaise, apathy or irritability, some lowering of cognitive functioning (learning difficulties), altered sleep and eating patterns, and changes in sexuality and in social judgment. There may be a variety of residual neurological dysfunctions such as paralysis, deafness, aphasia, constructional apraxia, and acalculia.

3) Post-concussional syndrome (F07.2)

- The syndrome occurs following head trauma (usually sufficiently severe to result in loss of consciousness) and includes a number of disparate symptoms such as:

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- Fatigue, irritability, difficulty in concentrating and performing mental tasks, impairment of memory, insomnia

- Insomnia

- Reduced tolerance to alcohol

- Reduced tolerance to stress, emotional excitement

- Feelings of depression or anxiety, resulting from some loss of self-esteem and fear of permanent brain damage

- At least three of the features described above should be present for a definite diagnosis

- Such feelings enhance the original symptoms and a vicious circle results. Some patients become hypochondriacal, embark on a search for diagnosis and cure, and may adopt a permanent sick role.

- Careful evaluation with laboratory techniques (electroencephalography, brain stem evoked potentials, brain imaging, oculonystagmography) may yield objective evidence to substantiate the symptoms but results are often negative. The complaints are not necessarily associated with compensation motives. Includes:

+ Postcontusional syndrome (encephalopathy)

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4) Other organic personality and behavioural disorders due to brain disease, damage and dysfunction (F07.8.)

- Brain disease, damage, or dysfunction may produce a variety of cognitive, emotional, personality, and behavioural disorders, not all of which are classifiable under the preceding rubrics. However, since the nosological status of the tentative syndromes in this area is uncertain, they should be coded as "other".

Also code here:

- Any other specified but presumptive syndromes of personality or behavioural change due to brain disease, damage, or dysfunction other than those listed under F07.0-F07.2; and

- conditions with mild degrees of cognitive impairment not yet amounting to dementia in progressive mental disorders such as Alzheimer disease, Parkinson disease, etc. The diagnosis should be changed when the criteria for dementia are fulfilled.

Unspecified organic personality and behavioural disorders due to brain disease, damage and dysfunction (F07.9.)

- Includes: organic psychosyndrome

4. TREATMENT

4.1. Treatment rules

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- Patient care and monitoring play an important role in treatment of recoverable disorders such as post-encephalitic syndrome and post-concussional syndrome.

- As personality and behavioural disorders are organic residuals, it is essential to combine treatment with patient management and education.

4.2. Treatment regimens

Treatment of secondary personality syndromes is first directed toward correcting the underlying cause.

Some mood stabilizers for control of emotions and impulses:

Sodium valproate 200mg - 2500mg/day

Divalproex sodium 750mg/day - 60mg/kg/day

Carbamazepine 100 - 1600mg/day

Oxcarbazepine 300 - 2400mg/day

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Levetiracetam 500 - 1500mg/day

Tranquilizers: Select one, two or three drug(s) from the following list:

Risperidone 1mg - 10mg/day

Quetiapine 50mg - 800mg/day

Olanzapine 5mg - 30mg/day

Clozapine 25 - 300mg/day

Aripiprazole 10 - 30mg/day

Haloperidol 0,5 mg - 20mg/day

Antidepressants: Select one, two or three drug(s) from the following list:

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Sertraline 50mg - 200mg/day

Citalopram 10mg - 40mg/day

Escitalopram 10 - 20mg/day

Fluvoxamine 100mg - 200mg/day

Paroxetine 20mg - 50mg/day

Fluoxetine 10 - 60mg/day

Venlafaxine 75 mg - 375mg/day

Mirtazapine 15mg - 45mg/day

Anti-anxiety drugs (if necessary):

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Bromazepam 2 - 6mg/day

Zopiclone, zolpidem, zaleplon, etc.

Beta-blockers such as propranolol are also effective.

Propranolol 10 - 80mg/day

Cognitive enhancers:

Donepezil 5mg - 23mg/day

Rivastigmine 1,5mg - 12mg/day (oral dosage forms or transdermal patch)

Galantamine 8mg - 24mg/day

Neurological supplements and metabolism and cerebral circulation boosters:

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Ginkgo biloba 80mg - 120mg/day

Piracetam 400mg - 1200mg/day

Citicholine 100mg - 1000mg/day

Choline alfoscerate 200mg - 800mg/day

Vinpocetine 5mg - 100mg/day

Liver supplements: aminoleban, silymarin, boganic, other branched-chain amino acids.

The patient may receive dietary supplements, parenteral nutrition, etc.

Psychotherapy

- Direct psychotherapy: family therapy, individual therapy, etc.

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+ Ensure a safe environment for the patient and people around the patient

+ Ensure a tranquil environment with no external stimuli

+ Sleep hygiene

+ Educate the patient’s family on care for the patient, etc.

Physical rehabilitation and occupational therapy

Treat associated physical diseases, and assist the patient with activities of daily living, including bathing, personal hygiene, etc., to prevent complications arising from prolonged bed rest and enhance the patient's quality of life.

5. PROGNOSIS AND COMPLICATIONS

5.1. Prognosis

Symptoms of personality and behavioral disorders usually persist and are hard to treat as they are residuals of organic causes.

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5.2. Complications

Complications related to underlying diseases (i.e., infection, injuries, etc.) must be monitored and controlled.

Acts of impulsiveness or destruction, harming others, etc. brought forth by personality and behavioral disorders must be managed.

6. PREVENTION

As organic mental disorders are mostly caused by cerebral and non-cerebral diseases, it is essential to improve the patient’s condition via exercise, nutrition, appropriate occupational hygiene and healthy lifestyle.

Prevent and treat brain disorders early on. Make early prognoses of personality and behavioral disorders for timely intervention.

Part 7

MENTAL DISORDERS DUE TO USE OF ALCOHOL 

1. DEFINITION

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Alcohol-induced psychosis is a consequence of direct and long-term effects of alcohol on the brain.

2. CAUSES

Some factors influencing alcohol dependence include age; socio-cultural elements; genetics.

3. DIAGNOSIS

3.1. Diagnostic criteria for alcohol dependence

Alcohol dependence: according to ICD 10 (1992), three or more of the following manifestations should have occurred together for at least one month or if persisting for periods of less than one month then they have occurred together repeatedly within a twelve month period: a strong desire or sense of compulsion to use alcohol; impaired capacity to control use of alcohol in terms of onset, termination or level of use; a physiological withdrawal state when alcohol use is reduced or ceased; evidence of tolerance to the effects of alcohol, such that there is a need for markedly increased amounts of alcohol to achieve intoxication or desired effect; important alternative pleasures or interests being given up or reduced because of substance use; persisting with substance use despite clear evidence of harmful consequences.

Withdrawal syndrome: a typical manifestation of alcohol dependence that arises upon abrupt cessation or reduction of the amount of alcohol consumed. Three of the following signs must be present:

Tremor: tongue, eyelids and outstretched arms; sweating; nausea or vomiting; tachycardia or hypertension; psychomotor agitation; headache; insomnia; malaise or weakness; transient tactile, visual or auditory hallucinations or illusions; grand mal convulsions. Withdrawal syndrome can last from several hours to several days depending on the level of alcohol dependence.

3.2. Diagnostic criteria for alcohol-induced psychosis

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3.2.1. Withdrawal state with delirium (delirium tremens)

Withdrawal state with delirium is a type of acute and severe psychosis in chronic alcohol abusers when their bodies are weakened due to a disease (infection, injury, etc.), after absolute or relative withdrawal of alcohol or during an episode of heavy drinking.

Clinical:

a. Onset:

Withdrawal state with delirium may have sudden or gradual onset. Symptoms include weakness, lack of appetite, sleep disorders, neurovegetative disorders.

Mood change: panic, anxiety. The condition gradually worsens, especially in the evening, and there might be visual delusions, reminiscence, etc.

a. Illness:

There are delirium or confusion; severe tremors, vivid hallucinations and illusions. Delusions, aggression, insomnia, etc. are usually also present.

There are time and spatial disorientation and possibly topographical disorientation. Clouding of consciousness usually worsens in the evening.

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Delusions, especially persecutory delusions, are quite common.

There may be aggression, sleep disorders, etc.

There are marked systemic disorders, i.e., limb tremor; tongue tremor; sweating, mild fever, etc.

Symptoms usually last less than a week.

Differential diagnosis

Delirium not induced by alcohol; dementia; schizophrenia

3.2.2. Alcoholic hallucinosis

Alcoholic hallucinosis is a type of alcohol-induced psychosis in chronic alcohol abusers.

Clinical: acute or gradual onset, possibly with delusions,  auditory illusions; visual illusions; tactile hallucinations.

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Jealous delusions: arise from chronic alcohol dependence

Initially, the patient only suffer from jealous delusions when they are drunk, but the delusions eventually occur more frequently and are based on unfounded evidence.

Jealous delusions may be accompanied by thoughts about being stalked or poisoned.

Persecutory delusions: may co-occur with delusions of being stalked or jealous delusions, etc.

Diagnosis of alcohol-induced psychosis with prominent delusions/hallucinations

Psychosis appears during or immediately after use of alcohol (usually within 48 hours). Delusions/Hallucinations are most prominent.

Do not diagnose in case of polysubstance intoxication or withdrawal; or hallucinogen use. Do not diagnose in case the delusions/hallucinations appear prior to alcohol abuse or remission phases unrelated to alcohol.

Differential diagnosis of alcohol-induced delusions/hallucinations

Schizophrenia; withdrawal state with delirium (delirium tremens)

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Clinical

This disorder usually has an atypical picture and is characterized by rare mood decline, unstable mood, restlessness, irritability, assaultiveness, weakness, exhaustion, lack of interest, reduced activity.

Insomnia and nightmares are also common symptoms.

Diagnostic criteria:

Depressive symptoms begin within two weeks of alcohol consumption.

Depressive symptoms persist for more than 48 hours but not more than 6 months.

Differential diagnosis: depression occurring prior to alcohol dependence.

3.2.5. Alcohol-induced amnesia

Clinical: It is a chronic organic brain syndrome that is associated with alcohol. Korsakov syndrome develops in later stages of alcohol dependence.

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3.2.6. Paraclinical

- Pre- and post-treatment complete blood count

- Biochemical blood tests for glucose, urea, creatinine, uric acid; CK (pre- and post-treatment; perform daily in first week if there is any irregularity); electrolyte panel (pre- and post-treatment, perform daily in first week if there is any irregularity)’ GOT, GPT (pre-treatment and 1 week and 2 weeks post-treatment), GGT, protein, albumin, bilirubin TP and TT, lipids (cholesterol, triglyceride, LDL, HDL).

- Basic coagulation tests, urine analysis

- Blood/Breath alcohol concentration test

- Tests for microorganisms: HIV, HbsAg, Anti HCV, syphilis.

- Chest X-ray; abdominal ultrasound; gastroscopy, etc.

- Pre- and post-treatment psychological tests

- Determination of depression level (HDRS, Beck); anxiety level (HARS, Zung); alcohol use disorder level (AUDIT); alcohol withdrawal level (CIWA); personality characteristics (EPI, MMPI); sleep disorder level (PSQI); and/or assessment of cognitive impairment (MMSE), stress-anxiety-depression disorders (DASS), etc.

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- Daily performance of paraclinical tests upon detection of abnormality

4. TREATMENT

4.1. Treatment rules

Provide comprehensive and long-term intensive treatment

Combine medicinal chemistry approaches, psychotherapy and community-based rehabilitation

Medicinal chemistry approaches:

For alcohol withdrawal syndrome: hydration, electrolyte and high-dose B vitamins supplementation, minor tranquillizers, tranquilizers)

For alcohol-induced psychosis: tranquilizers, minor tranquillizers, hydration, electrolyte and high-dose B vitamins supplementation

For alcohol-induced depression: antidepressants, hydration, electrolyte and high-dose B vitamins supplementation

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- Individual therapy, family therapy

- Cognitive behavioural therapy

Community-based rehabilitation: social readaptation

Treat associated physical diseases (liver diseases, stomach diseases, respiratory diseases, etc.)

4.2. Treatment regimens

Detoxification and treatment of withdrawal syndrome by medications

Chemical aversion therapy and/or alcohol relapse prevention

Psychosis treatment for alcohol-induced psychosis with delusions/hallucinations

Depression treatment for alcohol-induced depression

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Cognitive enhancers: piracetam, ginkgo giloba, choline alfoscerate, vinpocetine, etc.

4.3. Specific treatment

4.3.1. Alcohol withdrawal syndrome

The patient needs to be hospitalized.

Administer benzodiazepines (10-30mg/day) by the oral, intramuscular or intravenous route to treat alcohol withdrawal syndrome; incorporate antipsychotic drugs if there are delusions, hallucinations, behavioral disorders, etc.

Antipsychotic drugs: select one or two or three drug(s) from the following list (prioritize single-drug therapy; if poorly effective, consider switching to another drug or combining a maximum of 3 drugs to minimize undesired effects)

Typical (Classic) tranquilizer:

Haloperidol: 1,5mg tablet, 5 mg tablet, 5mg injection with a dose of 5-30mg/24 hours

Atypical (New) tranquilizers:

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Olanzapine: 5mg/10mg tablet with a dose of 5-60mg/24 hours

Quetiapine 50mg, 200mg, 300mg with a dose of 600-800 mg/ day

Clozapine: 25mg/100mg tablet with a dose of 50-800mg/24 hours

Aripiprazole 5mg, 10 mg, 15mg, 30mg with a dose of 10-30 mg/ day

Hydration and electrolyte supplements: Ringer's lactate solution, sodium chloride 0,9 %, glucose 5% with an amount of 2-4 liters/day via intravenous infusion and/or oral rehydration salts

B vitamins (B1, B6, B12) supplements, especially a high dose of vitamin B1 at 1 g/day (preferably via injection)

Liver supplements: aminoleban, silymarin, boganic, other branched-chain amino acids.

The patient may receive dietary supplements, parenteral nutrition, etc.

Neurological supplements:

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Treatment of associated physical diseases. Psychotherapy

Physical rehabilitation, occupational therapy, etc.

Disulfiram 125-250 mg/day, naltrexone 25-50mg/day and other drugs may be used for outpatient treatment.

4.3.2. Treatment of withdrawal state with delirium

Diazepam10-30mg/day via oral route or intramuscular injection or intravenous injection

Antipsychotic drugs: select one or two or three drug(s) from the following list (prioritize single-drug therapy; if poorly effective, consider switching to another drug or combining a maximum of 3 drugs to minimize undesired effects)

Typical (Classic) tranquilizer:

Haloperidol: 1,5mg tablet, 5 mg tablet, 5mg injection with a dose of 5-30mg/24 hours

Atypical (New) tranquilizers:

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Olanzapine: 5mg/10mg tablet with a dose of 5 - 60mg/24 hours

Clozapine: 25mg/100mg tablet with a dose of 50 - 800mg/24 hours

Quetiapine: 50mg/200mg/300mg tablet with a dose of 600 - 800mg/day

Aripiprazole: 5mg/10mg/15mg/30mg tablet with a dose of 10 - 30mg/day

Hydration and electrolyte supplements: Ringer's lactate solution, sodium chloride 0,9 %, glucose 5% with an amount of 2 - 4 liters/day via intravenous infusion or oral rehydration salts

B vitamins (B1, B6, B12) supplements, especially a high dose of vitamin B1 at 1 g/day (preferably via injection)

Hepatoprotective medication: aminoleban, silymarin, boganic, other branched-chain amino acids.

Dietary supplements, parenteral nutrition

Neurological supplements

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Treatment of associated physical diseases

Severe delirium cases must receive intensive care or be transferred to intensive care units.

Psychotherapy

Physical rehabilitation, occupational therapy, etc.

4.3.3. Treatment of alcohol-induced psychosis

Antipsychotic drugs: select one or two or three drug(s) from the following list (prioritize single-drug therapy; if poorly effective, consider switching to another drug or combining a maximum of 3 drugs to minimize undesired effects)

Typical (Classic) tranquilizers:

Haloperidol: 1,5mg tablet, 5 mg tablet, 5mg injection with a dose of 5-30mg/24 hours

Chlorpromazine: 25mg tablet, 25mg injection with a dose of 50-250mg/24 hours

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Thioridazine: 50mg tablet with a dose of 100-300mg/24 hours

Atypical (New) tranquilizers:

Risperidone: 1mg/2mg tablet with a dose of 1-12mg/24 hours

Olanzapine: 5mg/10mg tablet with a dose of 5-60mg/24 hours

Amisulpride: 50mg/200mg/400mg tablet with a dose of 200-800mg/24 hours

Clozapine: 25mg/100mg tablet with a dose of 50-800mg/24 hours

Quetiapine 50mg/200mg/300mg tablet with a dose of 600-800 mg/ day

Aripiprazole: 5mg/10mg/15mg/30mg tablet with a dose of 10-30mg/day

Anti-anxiety drugs: select one of the following: benzodiazepine 5- 30mg/day, lorazepam, bromazepam, etc.

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Hydration and electrolyte supplements: Ringer's lactate solution, sodium chloride 0,9 %, glucose 5% with an amount of 1-3 liter(s)/day via intravenous infusion or oral rehydration salts

B vitamins (B1, B6, B12) supplements, especially a high dose of vitamin B1 at 1 g/day (preferably via injection)

Hepatoprotective medication: aminoleban, silymarin, boganic, other branched-chain amino acids.

Dietary supplements, parenteral nutrition

Neurological supplements:

Cognitive enhancers:

Sleep disorder drugs: select one of the following: zopiclone 3,75-15mg/day, melatonin, etc.

Physical rehabilitation, occupational therapy, etc.

Combine medicinal chemistry approaches, psychotherapy and social therapy to prevent alcohol relapse. May incorporate Disulfiram 125-250 mg/ day, Naltrexol 25-50mg/day

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Antidepressants: select one or two or three drug(s) from the following list (prioritize single-drug therapy; if poorly effective, consider switching to another drug or combining a maximum of 3 drugs to minimize undesired effects)

Selective serotonin reuptake inhibitors:

Fluoxetine 20mg with a dose of 10-40mg/day

Paroxetine 20mg with a dose of 20-60mg/day

Sertraline 50mg with a dose of 50-200mg/day

Fluvoxamine 100mg with a dose of 100-300mg/day

Escitalopram 10/20 mg with a dose of 10-20mg/day

Citalopram with a dose of 10-60mg/day

Dual-action drugs:

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Mirtazapine 30mg with a dose of 30-60mg/day

Tricyclic antidepressants:

Amitriptyline 25mg with a dose of 50-100mg/day

Clomipramine 25mg with a dose of 50-75mg/day

Imipramine with a dose of 10-150mg/day

Other types of antidepressants:

Tianeptine with a dose of 12,5 -50mg/day

Combine with antipsychotic drugs/benzodiazepine or non-benzodiazepine anti-anxiety drugs when necessary.

Hydration and electrolyte supplements: Ringer's lactate solution, sodium chloride 0,9 %, glucose 5% with an amount of 1-3 liter(s)/day via intravenous infusion or oral rehydration salts

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Hepatoprotective medication: aminoleban, silymarin, boganic, other branched-chain amino acids.

Dietary supplements, parenteral nutrition

Neurological supplements:

Cognitive enhancers:

Psychotherapy: individual therapy, family therapy, motivational therapy, cognitive behavioural therapy.

Community-based rehabilitation: social readaptation (therapeutic exercises, occupational therapy, employment creation for patients, etc.)

Diet:

Provide parenteral nutrition for patients who cannot eat

Provide nutritious and digestible food from all 4 food groups for patients who can eat

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5. PROGNOSIS AND COMPLICATIONS

Alcohol dependence is an acute progressive syndrome that requires prolonged treatment and cooperation between the patient’s family, multiple ministries and mass organizations and the community.

Alcohol dependence usually leads to personality change, potentially resulting in mental disorders and many physical diseases.

6. PREVENTION

6.1. Alcohol dependence prevention

Raise awareness of the effects of alcohol on the body, the mind and society

Provide strict regulations on production, distribution and use of alcohol

Focus on family of alcohol abusers, persons having crises, the mentally ill, etc.

6.2. Alcohol-induced psychosis prevention

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Treat physical disorders, enhance intake of B vitamins

Part 8

OPIOID DEPENDENCE

1. DEFINITION

Opioids are a class of substances that include natural substances (resin of the opium poppy), semi-synthetic substances and synthetic substances (morphine, heroin, methadone, etc.).

Opioid dependence encompasses both physical and psychological dependence. Psychological dependence is the biological basis of relapse.

2. CAUSES

2.1. Psychological causes

Young people’s curiosity or tendency to imitate adults and use alcohol, tobacco, narcotic substances, etc. to prove their maturity, etc.

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2.2. Social and familial causes

The patient is neglected, overindulged or have their opioid use covered by their family. There are frequent conflicts in the family.

Opioids are not strictly managed in the school. Governments fail to adopt effective measures against drug addict gatherings.

2.3. Biological causes: substance dependence is associated with mental illnesses

Depression, anxiety, schizophrenia, etc. Antisocial personality disorder, etc.

3. DIAGNOSIS

3.1. Opioid dependence

According to ICD 10 (1992), three or more of the following manifestations should have occurred together for at least one month or if persisting for periods of less than one month then they have occurred together repeatedly within a twelve month period: a strong desire or sense of compulsion to use opioids; impaired capacity to control use of opioids in terms of onset, termination or level of use; a physiological withdrawal state when opioid use is reduced or ceased; evidence of tolerance to the effects of opioids; important alternative pleasures or interests being given up or reduced because of opioid use; persisting with opioid use despite clear evidence of harmful consequences.

3.2. Opioid withdrawal syndrome

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Strong desire to use a type of opioid; nasal congestion or sneezing; eyes tearing; muscle pain or cramp; abdominal rigidity; nausea, vomiting; diarrhea; pupil dilation; goose bumps or shivering; tachycardia or hypertension; yawning; disturbed sleep

3.3. Paraclinical

Multi drug 4 or 6 panel test for morphine, amphetamine, MDMA and THC or urine test for opioids and other types of narcotic substances

Complete blood count (pre- and post-treatment; if there is abnormality, perform daily)

Urine analysis

Biochemical blood tests for glucose, urea, creatinine, uric acid, lipids (cholesterol, triglyceride, LDL, HDL); CK, GOT, GPT, GGT, electrolyte panel (pre- and post-treatment)

Tests for microorganisms: HIV, HbsAg, Anti HCV, syphilis.

Chest X-ray

Abdominal ultrasound

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The abovementioned psychological tests need to be performed pre- and post-treatment.

Additional psychological tests include assessment of cognitive impairment (MMSE), stress-anxiety-depression disorders (DASS), determination of alcohol use disorder level (AUDIT) and alcohol withdrawal level (CIWA) if there is alcohol use, etc.

EEG, ECG, cerebral blood flow, CT, MRI, etc.

4. TREATMENT

4.1. General rules

- Choose the therapies that are suitable for the patient and capacity of the treatment facility

- After withdrawal syndrome treatment, provide continuation and long-term maintenance treatment to prevent relapse.

- Implement the biopsychosocial model and ensure close cooperation between doctors, the patient’s family and the community during the treatment process

- Withdrawal syndrome treatment: multiple methods (tranquilizer or clonidine use or psychotherapy, etc.)

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- Methadone or buprenorphine treatment

- Treatment of comorbid physical diseases (if any)

4.2. Treatment regimens

- Withdrawal syndrome treatment: multiple methods

- Relapse prevention maintenance therapy: naltrexone

- Methadone or buprenorphine treatment

4.3. Specific treatment

4.3.1. Withdrawal syndrome treatment

Anti-anxiety drugs: benzodiazepine derivatives such as diazepam 5 mg tablet (oral or intramuscular/intravenous route)

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Do not use diazepam if the patient is allergic to diazepam or has decompensated ventilatory failure/myasthenia gravis

First 2 days: 4 tablets every 4 hours until the patient is no longer restless and can sleep soundly. Continue to give the patient diazepam if they are still anxious after waking up

Third and fourth days: start reducing the doses: 2 tablets every 6-8 hours

Fifth day: stop giving diazepam completely to prevent diazepam dependence

 (May use diazepam for a longer period if necessary)

Tranquilizer: levomepromazine

Use levomepromazine only when there are severe symptoms (writhing, aggression, etc.) or complex symptoms (feeling of maggots crawling inside bones, etc.)

Dosage form: levomepromazine 25mg  compressed tablet

First dose: 2 tablets

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Third dose: 4 tablets if, after one hour, the patient is not yet calm and maximum blood pressure is equal to or higher than 100mmHg

Fourth dose and subsequent doses: 2 tablets if, after two hours, the patient is not yet calm and maximum blood pressure is equal to or higher than 100mmHg

Stop using levomepromazine if withdrawal syndrome does not occur after the patient wakes up. Take care of the patient and monitor their blood pressure regularly.

May incorporate other tranquilizers if there is any mood or behavioral disorder arising.

Analgesic drug: paracetamol

Administer 2 paracetamol 0,5g tablets twice or thrice a day for up to 3 days if there is a lot of muscle pain. 

Antispasmodic drugs: Spasfon

Administer 2 Spasfon 80mg compressed tablet twice or thrice a day if the patient experiences abdominal pain due to gastrointestinal tract spasms

Anti-diarrhea drugs and dehydration treatment

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If prolonged diarrhea and sweating lead to dehydration, provide the patient with oresol solutions (oral glucose-electrolyte solutions)

Clonidine

1/2 – 1 clonidine 0,15mg  tablet/dose, 2 – 8 tablets/day, administer the next dose upon presence of withdrawal syndrome

Suspend use of clonidine when blood pressure is under 90/60 mmHg or heart rate is below 60 beats/minute; if blood pressure/heart rate is stable after 30 minutes, continue use of clonidine.

Administer the abovementioned dose for 3 days; start to reduce the dose on the fourth day; discontinue use after 10 days if all withdrawal symptoms disappear.

May incorporate diazepam for 3-5 days more if the patient sleeps poorly or feels very restless or agitated.

May incorporate paracetamol if the patient experiences much joint/muscle pain

Hydration and electrolyte supplements: Ringer's lactate solution, sodium chloride 0,9%, glucose 5% with an amount of 1-2 liter(s)/day via intravenous infusion or oral rehydration salts

Supplementation of B vitamins (B1, B6, B12), etc.

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Dietary supplements, parenteral nutrition

Neurological supplements:

Cognitive enhancers:

4.3.2. Relapse prevention maintenance therapy

Naltrexone instructions for use

Preparation:

Clinical examination: the patient’s general condition, pregnancy status (for female patients)

Laboratory tests: complete blood count, liver function tests (SGOT, SGPT), kidney function tests (urine protein); urine tests for opioids (thin-layer chromatography or dipstick test), especially naloxone tests to ensure the urine is free of opioids.

Naltrexone regimen:

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1 tablet/ day for the first 2-3 weeks (50 mg naltrexone hydrochloride). Administer every-other-day dosing for the following weeks:

Monday: 1-2 tablet(s) (50-100 mg naltrexone hydrochloride)

Wednesday: 1-2 tablet(s) (50-100 mg naltrexone hydrochloride)

Friday: 1-3 tablet(s) (50-150 mg naltrexone hydrochloride) Or

Tuesday: 1-2 tablet(s) (50-100 mg naltrexone hydrochloride)

Thursday: 1-2 tablet(s) (50-100 mg naltrexone hydrochloride)

Saturday: 1-3 tablet(s) (50-150 mg naltrexone hydrochloride)

Monitoring:

Perform urine tests for opioids once every 2 weeks for the first month and once every 4 weeks for the following months; perform ad hoc urine tests in case of suspicion.

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Handling of undesired effects happened with the first days of use

Insomnia, restlessness: 1-2  diazepam 5mg tablet(s) before sleep

Stomachache: 1-2 alverine citrate 40 mg tablet(s)

Diarrhea: oresol solutions taken per instructions

Headache: 1 paracetamol 500mg tablet

Nausea: primperan 10mg

Vertigo: cinarizine 25mg/day, etc.

Weakness: dietary supplementation, parenteral nutrition

Liver supplements, cognitive enhancers, etc.

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Dose testing phase:

The dose testing phase usually lasts for 2 weeks, starting with 15 – 30 mg depending on each patient’s condition (low dose: 15 – 20 mg, medium dose: 20 – 25 mg, high dose 25 – 30 mg). Pay special attention to and monitor patients administered the high dose. Do not increase the dose in the first 3 days (unless the patient still experiences severe withdrawal syndrome).

Withdrawal syndrome will diminish but will not disappear completely; if there is any sign of intoxication, reduce the dose.

After 3 – 5 days of treatment, if withdrawal syndrome persists, increase 5 – 10mg/day; total amount of increased doses in a week shall not exceed 20mg.

Dose adjustment phase:

The dose adjustment phase usually begins in the third week and lasts for 1-3 month(s). The doctor shall monitor manifestations of withdrawal syndrome and desire for opioids of the patient. Increase 5 – 15mg/day after 3 – 5 days and total amount of increased doses in a week shall not exceed 30mg.

Dose maintenance phase:

This is the phase where the doses are effective with no desire to take opioids and minimal side effects. The doses taken depend on each patient’s condition with an average of 60 – 120 mg and a minimum of 15mg/day.

Treatment cessation:

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For doses of more than 40mg/day: reduce by 10mg/1 time/1 week.

For doses of less than 40mg/day: reduce by 5mg/1 time/1 week. With this dose, the patient can stop taking methadone completely without needing to reduce the doses.

Treatment skipping and resumption:

1-day skipping: no dose adjustment

2-day skipping: normal dose if no sign of intoxication

3-day skipping: examine the patient and consider administering the normal dose

4-day skipping: examine the patient and administer half of the dose

5-day skipping: examine the patient and consider administering half of the dose

Skipping more than 5 days: restart treatment

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Clinical progress monitoring:

High-risk behaviors during the treatment process. Progress of associated physical diseases.

Condition of pregnant patients during the treatment process.

Urine test results for methadone dose adjustment or upon suspicion of illegal opioid use during the treatment process.

If the patient continues to use opioids after repeated advice, consider stopping the treatment if necessary. The patient must take methadone daily under strict supervision of healthcare workers in cooperation with the patient’s family, the community and social organizations.

Diet: nutritious, digestible and safe food from all 4 food groups

Community-based rehabilitation: occupational therapy

5. PROGNOSIS AND COMPLICATIONS

Opioid dependence is an acute progressive syndrome that requires prolonged treatment and cooperation between the patient’s family, multiple ministries and mass organizations and the community.

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Other complications include risks of HIV or hepatitis B/C transmission, etc.

6. PREVENTION

Raise awareness of the effects of opioids on the body, the mind and society. Guide young people towards a healthy lifestyle.

Strictly handle illegal opioid production, distribution and use, and manage and use legal opioids per prescription and for the intended purpose.

Focus on family of opioid users, persons having crises, the mentally ill, etc.

Part 9

MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF CANNABINOIDS

1. DEFINITION

Cannabis, also known as marijuana, hemp, weed, etc., has long been used to produce fiber or for medical purpose or as a narcotic substance. Cannabis can be smoked (rolled into joints, mixed with tobacco, smoked using a pipe), drunk or eaten.

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Cannabis is a common and accessible narcotic substance. Cannabis use is legal in some countries

Factors leading to cannabis use:

- Behavioural disorders in children and adolescents, antisocial personality disorder

- Environment: bad academic performance, smoking, dysfunctional family, etc.

- Biological factors: genetic factors, etc.

3. DIAGNOSIS

3.1. Diagnosis

3.1.1. Acute cannabinoid intoxication (ICD 10- F12.0)

- Clear evidence of recent use of cannabis at sufficiently high dose levels to be consistent with intoxication.

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- At least one of the following symptoms: euphoria and disinhibition; anxiety or agitation; suspiciousness or paranoid ideation; temporal slowing; impaired judgment; impaired attention; impaired reaction time; auditory, visual or tactile illusions; hallucinations with preserved orientation; depersonalization; derealization; or interference with personal functioning.

- At least one of the following signs: increased appetite; dry mouth; conjunctival injection; or tachycardia.

- The abovementioned signs cannot be accounted for by a medical disorder unrelated to cannabis use, and not better accounted for by another mental or behavioural disorder.

3.1.2. Harmful cannabis use (F12.1)

- Clear evidence that the cannabis use was responsible for physical or psychological harm, including impaired judgment or dysfunctional behavior, potentially leading to loss of ability to form personal relationships or negative consequences for personal relationships.

- The nature of the harm should be clearly identifiable (and be able to satisfied researchers).

- The pattern of use has persisted for at least one month or has occurred repeatedly within a twelve-month period

- The disorder does not meet the criteria for any other cannabis-induced mental or behavioural disorder in the same time period (except for acute cannabinoid intoxication).

3.1.3. Cannabis dependence syndrome (F12.2)

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+ A strong desire or sense of compulsion to use cannabis

+ Impaired capacity to control cannabis use

+ A physiological withdrawal state when cannabis use is significantly reduced or ceased

+ Evidence of a need for markedly increased amounts of cannabis to achieve desired effect

+ Important alternative pleasures or interests being given up or reduced

+ Persisting with cannabis use despite clear evidence of cannabis’ harmful consequences for the patient, their family and the society

3.1.4. Withdrawal state (F12.3)

- Clear evidence of recent cessation or reduction of cannabis use after repeated, and usually prolonged and/or high-dose cannabis use

- Or a (physiological) withdrawal state (in heavy cannabis users):

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+ Insomnia

+ Lack of appetite

+ Mild nausea

+ Tremor, sweating, muscle pain, etc.

+ Lasting from several hours to up to seven days.

- The abovementioned signs cannot be accounted for by a medical disorder unrelated to cannabis use, and not better accounted for by another mental or behavioural disorder.

3.1.5. Cannabis-induced psychosis (F12.5)

Diagnostic criteria:

- Onset of psychotic symptoms during or within two weeks of cannabis use

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- Duration of the disorder not exceeding six months (if exceeding six months, residual and late-onset psychotic disorder due to cannabis use (F12.7) should be considered).

3.2. Differential diagnosis

Mental disorders due to use of other sedative-hypnotics

3.3. Paraclinical

- Multi drug 4 or 6 panel test for cannabinoids and other narcotic substances

- Biochemical blood tests for drugs performed in qualified laboratories

- Pre- and post-treatment complete blood count

- Biochemical blood tests:

- Glucose, urea, creatinine, uric acid, lipids (cholesterol, triglyceride, LDL, HDL)

...

...

...

- Tests for microorganisms: HIV, HbsAg, Anti HCV, syphilis.

- Urine analysis

- Chest X-ray

- Abdominal ultrasound

- Psychological tests for determination of:

- Depression level (HDRS, Beck)

- Anxiety level (HARS, Zung)

- Personality characteristics (EPI, MMPI)

- Sleep disorder level (PSQI)

...

...

...

- Additional psychological tests include assessment of cognitive impairment (MMSE), stress-anxiety-depression disorders (DASS), determination of alcohol use disorder level (AUDIT) and alcohol withdrawal level (CIWA) if there is alcohol use, etc.

- ECG

- EEG, cerebral blood flow, CT, MRI, etc.

- Paraclinical tests must be performed daily upon detection of abnormality.

- Paraclinical tests shall be performed based on specialized medical consultation upon detection of abnormality.

4. TREATMENT

4.1. Treatment rules

- Treat symptoms and identify the mental disorders accurately

- Select appropriate drugs and administer the correct dosage

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...

- Tranquilizers (upon presence of psychotic symptoms such as delusions, hallucinations, aggression, etc.)

- Antidepressants (upon signs of depression, anxiety, etc.)

- Minor tranquillizers, anti-anxiety drugs

- Psychotherapy: individual therapy, family therapy

4.2. Treatment regimens

- Medicinal chemistry approaches

- Minor tranquillizers

- Antipsychotic drugs

- Antidepressants

...

...

...

4.3. Specific treatment: depending on each patient’s condition and clinical picture

Antipsychotic drugs: select one or two or three drug(s) from the following list (prioritize single-drug therapy; if poorly effective, consider switching to another drug or combining a maximum of 3 drugs to minimize undesired effects)

Typical (Classic) tranquilizers:

Chlorpromazine: 25mg tablet, 25mg injection with a dose of 50-250mg/24 hours

Levomepromazine: 25mg tablet with a dose of 25-250mg/24 hours

Haloperidol: 1,5mg tablet, 5 mg tablet, 5mg injection with a dose of 5-30mg/24 hours

Thioridazine: 50mg tablet with a dose of 100-300mg/24 hours

Atypical (New) tranquilizers:

Amisulpride: 50mg/200mg/400mg tablet with a dose of 200-800mg/24 hours

...

...

...

Risperidone: 1mg/2mg tablet with a dose of 1-12mg/24 hours

Olanzapine: 5mg/10mg tablet with a dose of 5-60mg/24 hours

Quetiapine 50mg/200mg/300mg tablet with a dose of 600-800 mg/ day

Aripiprazole: 5mg/10mg/15mg/30mg tablet with a dose of 10-30mg/day

Antidepressants: select one or two or three drug(s) from the following list (prioritize single-drug therapy; if poorly effective, consider switching to another drug or combining a maximum of 3 drugs to minimize undesired effects)

Selective serotonin reuptake inhibitors:

Fluoxetine 20mg with a dose of 10-40mg/day

Paroxetine 20mg with a dose of 20-60mg/day

Sertraline 50mg with a dose of 50-200mg/day

...

...

...

Escitalopram 10/20 mg with a dose of 10-20mg/day

Citalopram with a dose of 10-60mg/day

Dual-action drugs:

Venlafaxine 37,5mg with a dose of 75-225mg/day

Mirtazapine 30mg with a dose of 30-60mg/day

Tricyclic antidepressants:

Amitriptyline 25mg with a dose of 50-100mg/day

Clomipramine 25mg with a dose of 50-75mg/day

Imipramine with a dose of 10-150mg/day

...

...

...

Tianeptine with a dose of 12,5 -50mg/day

Mood stabilizers: select one or two or three drug(s) from the following list (prioritize single-drug therapy; if poorly effective, consider switching to another drug or combining a maximum of 2 drugs to minimize undesired effects)

Sodium valproate 200mg-2500mg/day

Divalproex sodium with a dose of 750mg/day - 60mg/kg/day

Carbamazepine with a dose of 400-1200mg/day

Oxcarbazepine with a dose of 1200 - 2400mg/day

Lamotrigine with a dose of 100 - 400mg/day

Topiramate: 50 – 400mg/day

Gabapentin: 300 – 1800mg/day

...

...

...

Diazepam: 5 - 30mg/day

Lorazepam: 1 - 4mg/day

Clonazepam: 1 - 8mg/day

Bromazepam: 3 - 6mg/day

Other anti-anxiety drugs and sleeping pills: select one of the following: etifoxine, tofisopam, passiflora foetida, zopiclone, eszopiclone, melatonin.

Other drugs: cerebral circulation boosters and neurological supplements (piracetam, citicoline, ginkgo biloba, vinpocetine, choline alfoscerate, cinnarizine, etc.), vitamins and micronutrients, antihistamines (hydroxyzine, etc.), beta blockers, etc.

Dietary supplements, parenteral nutrition

Hepatoprotective medications: aminoleban, silymarin, boganic, other branched-chain amino acids.

Cognitive enhancers

...

...

...

Treatment of associated physical diseases

Diet: nutritious, digestible and safe food from all 4 food groups

Community-based rehabilitation: occupational therapy

5. PROGNOSIS AND COMPLICATIONS

5.1. Prognosis

The disorders are usually chronic and require long-term treatment.

5.2. Complications

Complications are usually associated with use of tranquilizers, extrapyramidal side effects, parkinsonian syndromes, etc.

6. PREVENTION

...

...

...

Exercise state management of drugs in general and narcotic substances, including cannabinoids, in particular

Raise awareness of the harmful effects of cannabinoids to deter people from using cannabinoids

Level 2 prevention:

Screen cannabinoid users to detect mental disorders early on

Level 3 prevention:

Manage cannabinoid users with existing mental disorders

Part 10

MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF COCAINE

1. DEFINITION

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...

...

2. CAUSES

Comorbid mental disorders such as bipolar affective disorder, schizophrenia, behavioural disorders in children and adolescents or antisocial personality disorder in adults.

Family and environmental factors: cocaine use by parents, childhood family violence, dysfunctional family, etc.

Use of other narcotic substances.

3. DIAGNOSIS

3.1. Diagnosis

3.1.1. Acute cocaine intoxication (ICD 10- F14.0)

- Clear evidence of recent use of cocaine at sufficiently high dose levels to be consistent with intoxication.

- Presence of the following symptoms or signs of intoxication:

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...

- At least two of the following signs: tachycardia (sometimes bradycardia); cardiac arrhythmias; hypertension (sometimes hypotension); sweating and chills; nausea or vomiting; evidence of weight loss; pupillary dilatation; psychomotor agitation (sometimes retardation); muscular weakness; chest pain; convulsions.

3.1.2. Harmful cocaine use (F14.1)

- Clear evidence that the cocaine use was responsible for physical or psychological harm, including impaired judgment or dysfunctional behavior, potentially leading to loss of ability to form personal relationships or negative consequences for personal relationships.

+ The nature of the harm should be clearly identifiable (and be able to satisfied researchers).

+ The pattern of use has persisted for at least one month or has occurred repeatedly within a twelve-month period

+ The disorder does not meet the criteria for any other cocaine-induced mental or behavioural disorder in the same time period (except for acute cocaine intoxication).

3.1.3. Cocaine dependence syndrome (F14.2)

- Three or more of the following manifestations s should have occurred together for at least one month or if persisting for periods of less than one month then they have occurred together repeatedly within a twelve-month period.

+ A strong desire or sense of compulsion to use cocaine

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...

+ A physiological withdrawal state when cocaine use is significantly reduced or ceased

+ Evidence of a need for markedly increased amounts of cocaine to achieve desired effect

+ Important alternative pleasures or interests being given up or reduced

+ Persisting with cocaine use despite clear evidence of cocaine’s harmful consequences for the patient, their family and the society

3.1.4. Withdrawal state (F14.3)

- Clear evidence of recent cessation or reduction of cocaine use after repeated, and usually prolonged and/or high-dose cocaine use

+ Dysphoric mood (for instance sadness or anhedonia)

+ A (physiological) withdrawal state (in heavy cocaine users)

+ Lethargy and fatigue

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...

+ Craving for cocaine

+ Increased appetite

+ Insomnia or hypersomnia

+ Bizarre or unpleasant dreams

- The abovementioned signs cannot be accounted for by a medical disorder unrelated to cocaine use, and not better accounted for by another mental or behavioural disorder.

3.1.5. Cocaine-induced psychosis (F14.5)

- Diagnostic criteria:

+ Onset of psychotic symptoms during or within two weeks of cocaine use

+ Persistence of the psychotic symptoms for more than 48 hours

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...

3.2. Paraclinical

- Quick urine tests for cocaine

- Multi drug 4 or 6 panel test for other narcotic substances

- Biochemical blood tests for drugs performed in qualified laboratories/poison centers

- Pre- and post-treatment complete blood count

- Biochemical blood tests for glucose, urea, creatinine, uric acid, lipids (cholesterol, triglyceride, LDL, HDL), CK, GOT, GPT, GGT, electrolyte panel (pre- and post-treatment)

- Tests for microorganisms: HIV, HbsAg, Anti HCV, syphilis.

- Urine analysis

- Chest X-ray

...

...

...

- ECG and heart ultrasound: should be regularly indicated due to the serious and common effects of cocaine on the cardiovascular system.

- Abdominal ultrasound

- Psychological tests for determination of:

- Depression level (HDRS, Beck); anxiety level (HARS, Zung, etc.); personality characteristics (EPI, MMPI, etc.); sleep disorder level (PSQI)

- The abovementioned psychological tests need to be performed pre- and post-treatment.

- Additional psychological tests include assessment of cognitive impairment (MMSE), stress-anxiety-depression disorders (DASS), determination of alcohol use disorder level (AUDIT) and alcohol withdrawal level (CIWA) if there is alcohol use, etc.

- EEG, cerebral blood flow, cranial  CT, cranial MRI, etc.

4. TREATMENT

4.1. Treatment rules

...

...

...

- Select appropriate drugs and administer the correct dosage

- Psychotherapy

4.2. Treatment regimens

- Medicinal chemistry approaches

- Minor tranquillizers

- Tranquilizers

- Antidepressants

- Treatment of comorbid conditions

- Psychotherapy: individual therapy, family therapy, etc.

...

...

...

Antipsychotic drugs: select one or two or three drug(s) from the following list (prioritize single-drug therapy; if poorly effective, consider switching to another drug or combining a maximum of 3 drugs to minimize undesired effects)

Typical (Classic) tranquilizers:

Chlorpromazine: 25mg tablet, 25mg injection with a dose of 50-250mg/24 hours

Levomepromazine: 25mg tablet with a dose of 25-250mg/24 hours

Haloperidol: 1,5mg tablet, 5 mg tablet, 5mg injection with a dose of 5-30mg/24 hours

Atypical (New) tranquilizers:

Amisulpride: 50mg/200mg/400mg tablet with a dose of 200-800mg/24 hours

Clozapine: 25mg/100mg tablet with a dose of 50-800mg/24 hours

Risperidone: 1mg/2mg tablet with a dose of 1-12mg/24 hours

...

...

...

Quetiapine 50mg/200mg/300mg tablet with a dose of 600-800 mg/ day

Aripiprazole: 5mg/10mg/15mg/30mg tablet with a dose of 10-30mg/day

Antidepressants: select one or two or three drug(s) from the following list (prioritize single-drug therapy; if poorly effective, consider switching to another drug or combining a maximum of 3 drugs to minimize undesired effects)

Selective serotonin reuptake inhibitors:

Fluoxetine 20mg with a dose of 10-40mg/day

Paroxetine 20mg with a dose of 20-60mg/day

Sertraline 50mg with a dose of 50-200mg/day

Fluvoxamine 100mg with a dose of 100-300mg/day

Escitalopram 10/20 mg with a dose of 10-20mg/day

...

...

...

Dual-action drugs:

Venlafaxine 37,5mg with a dose of 75-225mg/day

Mirtazapine 30mg with a dose of 30-60mg/day

Tricyclic antidepressants:

Amitriptyline 25mg with a dose of 50-100mg/day

Clomipramine 25mg with a dose of 50-75mg/day

Imipramine with a dose of 10-150mg/day

Other types of antidepressants:

Tianeptine with a dose of 12,5 -50mg/day

...

...

...

Sodium valproate with a dose of 1200-1500mg/day and maximum dose of 60mg/kg/day

Divalproex with a dose of 750mg/day – 60mg/kg/day

Carbamazepine with a dose of 400-1200mg/day

Oxcarbazepine with a dose of 1200 – 2400mg/day

Lamotrigine with a dose of 100 – 400mg/day

Topiramate: 50 – 400mg/day

Gabapentin: 300 – 1800mg/day

Benzodiazepines: select one from the following list:

Diazepam: 5 - 30mg/day

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...

...

Clonazepam: 1 - 8mg/day

Bromazepam: 3 - 6mg/day

Other anti-anxiety drugs and sleeping pills: select one of the following: etifoxine (stresam…),, tofisopam, passiflora foetida, zopiclone, eszopiclone, melatonin.

Other drugs: cerebral circulation boosters and neurological supplements (piracetam, citicoline, ginkgo biloba, vinpocetine, choline alfoscerate, cinnarizine, etc.), vitamins and micronutrients, antihistamines (hydroxyzine, etc.), beta blockers, etc.

Dietary supplements, parenteral nutrition

Hepatoprotective medications: aminoleban, silymarin, boganic, other branched-chain amino acids.

Cognitive enhancers: etc.,

Physical rehabilitation, occupational therapy, etc.

Treatment of comorbid conditions, etc.

...

...

...

Diet: nutritious, digestible and safe food from all 4 food groups

Community-based rehabilitation: occupational therapy

5. PROGNOSIS AND COMPLICATIONS

5.1. Prognosis: the disorders are usually chronic and require long-term treatment.

5.2. Complications

Respiratory system: bronchus/lung damage

Nose and throat: nasal mucosal hyperemia/ulcers

Hepatitis B/C and HIV infection

Neurological complications: dystonia, migraine, possible brain infarction, seizures

...

...

...

Death

6. PREVENTION

Level 1 prevention:

Exercise state management of drugs in general and narcotic substances, including cocaine, in particular.

Raise awareness of the harmful effects of cocaine to deter people from using cocaine.

Level 2 prevention:

Screen cocaine users to detect mental disorders early on.

Level 3 prevention:

Manage cocaine users with existing mental disorders.

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...

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MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF HALLUCINOGENS

1. DEFINITION

Hallucinogens are a class of substances that stimulate the central nervous system, enhance wakefulness, increase physical activity and pleasure, etc. and cause mental disorders such as anxiety, depression, sleep disorders, delusions, hallucinations, aggression, violence, etc. Hallucinogens include lysergic acid diethylamide (LSD), psilocybin, mescaline, peyote, amphetamines (ATS), some organic solvents, etc.

2. CAUSES

Easy synthesis of hallucinogens.

Use in multiple ways: smoking, inhalation, drinking, etc.

Misguided notion that it is trendy to use hallucinogens from some people (especially the youth); persuasion.

3. DIAGNOSIS

3.1. Diagnostic criteria for hallucinogen dependence

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A strong desire or sense of compulsion to use hallucinogens; impaired capacity to control use of hallucinogens in terms of frequency and amount; a physiological withdrawal state when hallucinogen use is reduced or ceased; increase in amount of hallucinogen used; important alternative pleasures or interests being given up or reduced; persisting with hallucinogen use despite clear evidence of harmful consequences.

3.2. Diagnostic criteria for mental disorders due to use of hallucinogens

Common diagnostic criteria for mental disorders due to use of hallucinogens (according to ICD-10):

Onset of symptoms during or within two weeks of hallucinogen use

Persistence of symptoms for more than 48 hours

Duration of the disorder not exceeding six months (if exceeding six months, residual and late-onset psychotic disorder due to hallucinogen use (F16.7) should be considered).

Do not diagnose if psychosis develops before hallucinogen dependence

Mental disorders due to Methamphetamine use can manifest as sleep disorders, anxiety disorders, depression, delusions, hallucinations, aggression and violence.

3.2.1. Sleep disorders

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...

3.2.2. Anxiety disorders

The patient experiences fear and/or tremors and/or is concern about their physical and mental health.

3.2.3. Depressive disorder

There is/are low mood, decreased interest/attention, reduced energy, weakness, decreased activity. There is irritability or even suicide in some cases.

3.2.4. Hallucinations

The patient usually experiences diverse hallucinations, starting with false perceptions such as vivid colors or frightening or demonic surroundings.

Sounds become lively, causing the patient to think they are in a strange world, before turning into real hallucinations, usually auditory hallucinations, i.e., voices of criticism, praise, disapproval or sometimes threats or condemnation towards the patient.

3.2.5. Delusions

At first, the patient feels doubt and, occasionally, perplexity accompanied by anxiety disorders or fear and eventually resulting in actual delusions.

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...

3.2.6. Intermittent explosive disorder

Use of hallucinogens can result in excitement, enhanced energy, increased motor activity, increased walking and, possibly, enhanced libido at first, and eventually lead to loss of control, disorientation, aggression (screaming, destroying, attacking other people, having no sense of self-preservation). This disorder is common in people intoxicated with hallucinogens or suffering from persecutory delusions.

Differential diagnosis

Aggression in schizophrenia, mania in bipolar affective disorder. Aggression in organic brain diseases such as brain tumors, encephalitis, temporal lobe epilepsy, etc. Aggression due to alcohol use and intoxication with other narcotic substances, psychotropic drugs, etc.

3.3. Paraclinical

- Multi drug 4 or 6 panel test for narcotic substances

- Biochemical blood tests for narcotic substances performed in qualified laboratories/poison centers

- Complete blood count, performed pre- and post-treatment or daily in the first week if there is any abnormality

- Biochemical blood tests for glucose, urea, creatinine, uric acid, CK (performed pre- and post-treatment or daily in first week if there is any irregularity); electrolyte panel (performed pre- and post-treatment or daily in first week if there is any irregularity)’ GOT, GPT (pre-treatment and 1 week and 2 weeks post-treatment); GGT, protein, albumin, bilirubin, lipids (cholesterol, triglyceride, LDL, HDL).

...

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- Urine analysis

- Chest X-ray

- Abdominal ultrasound

- Psychological tests for determination of:

- Depression level (HDRS, Beck)

- Anxiety level (HARS, Zung)

- Alcohol use disorder level (AUDIT) if there is alcohol use

- Personality characteristics (EPI, MMPI)

- Sleep disorder level (PSQI)

...

...

...

- Additional psychological tests include assessment of cognitive impairment (MMSE), stress-anxiety-depression disorders (DASS), etc.

- ECG

- EEG, cerebral blood flow, cranial  CT, cranial MRI, etc.

- Paraclinical tests must be performed daily upon detection of abnormality

- Paraclinical tests shall be performed based on specialized medical consultation upon detection of abnormality.

4. TREATMENT

4.1. Treatment rules

Maintain life functions such as by providing emergency care for other life-threatening internal medicine diseases. If the patient is being aggressive, inject antipsychotic drug(s).

When the patient is no longer in life-threatening condition and develops any mental disorder, treat the patient based on the clinical picture.

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Minor tranquilizers and anti-anxiety drugs: Select one, two or three drug(s) from the following list:

Benzodiazenpines with a dose of 5-30 mg/day for 1 week; avoid prolonged use (unless necessary)

Non-benzodiazepine anti-anxiety drugs: etifoxine 50-200mg/day, sedanxio, etc.

Sleep disorder drugs: zopiclone 3,75-15mg/day, melatonin, etc.

Contraindications: severe renal failure, liver failure, respiratory failure, myasthenia gravis, drug sensitivity.

Antidepressants: select one or two or three drug(s) from the following list (prioritize single-drug therapy; if poorly effective, consider switching to another drug or combining a maximum of 3 drugs to minimize undesired effects):

Selective serotonin reuptake inhibitors:

Fluoxetine 20mg with a dose of 10-40mg/day

Paroxetine 20mg with a dose of 20-60mg/day

...

...

...

Fluvoxamine 100mg with a dose of 100-300mg/day

Escitalopram 10/20 mg with a dose of 10-20mg/day

Citalopram with a dose of 10-60mg/day

Dual-action drugs:

Venlafaxine 37,5mg with a dose of 75-225mg/day

Mirtazapine 30mg with a dose of 30-60mg/day

Tricyclic antidepressants:

Amitriptyline 25mg with a dose of 50-100mg/day

Clomipramine 25mg with a dose of 50-75mg/day

...

...

...

Other types of antidepressants:

Tianeptine with a dose of 12,5 -50mg/day

Antipsychotic drugs: select one or two or three drug(s) from the following list (prioritize single-drug therapy; if poorly effective, consider switching to another drug or combining a maximum of 3 drugs to minimize undesired effects):

Typical (Classic) tranquilizers:

Chlorpromazine: 25mg tablet, 25mg injection with a dose of 50-250mg/24 hours

Levomepromazine: 25mg tablet with a dose of 25-250mg/24 hours

Haloperidol: 1,5mg tablet, 5 mg tablet, 5mg injection with a dose of 5-30mg/24 hours

Thioridazine: 50mg tablet with a dose of 100-300mg/24 hours

Atypical (New) tranquilizers:

...

...

...

Clozapine: 25mg/100mg tablet with a dose of 50-800mg/24 hours

Risperidone: 1mg/2mg tablet with a dose of 1-12mg/24 hours

Olanzapine: 5mg/10mg tablet with a dose of 5-60mg/24 hours

Quetiapine 50mg, 200mg, 300mg with a dose of 600-800 mg/ day

Aripiprazole 5mg, 10 mg, 15mg, 30mg with a dose of 10-30 mg/ day

Mood stabilizers: select one, two or three drug(s) from the following list to treat mania:

Sodium valproate 200mg-2500mg/day

Divalproex sodium 750mg/day - 60mg/kg/day

Carbamazepine with a dose of 400-1200mg/day

...

...

...

Lamotrigine 100 – 400 mg/day

Topiramate: 50 – 400mg/day

Gabapentin: 300 – 1800mg/day

Brain supplements:

Piracetam, citicoline, ginkgo biloba, vinpocetine, choline alfoscerate, cinnarizine, etc.

Dietary supplements, parenteral nutrition, etc.

Hepatoprotective medications: aminoleban, silymarin, boganic, other branched-chain amino acids.

Cognitive enhancers: etc.,

Physical rehabilitation, occupational therapy, etc.

...

...

...

Psychotherapy: individual therapy, family therapy, motivational therapy, cognitive behavioural therapy, social readaptation, etc.

Diet: nutritious, digestible and safe food from all 4 food groups

Community-based rehabilitation: occupational therapy

5. PROGNOSIS AND COMPLICATIONS

The prognosis is good if the patient is treated promptly. However, some cases can result in chronic psychosis or dementia.

6. PREVENTION

Level 1 prevention:

Exercise state management of drugs in general and narcotic substances, including amphetamines, in particular.

Raise awareness of the harmful effects of amphetamines to deter people from using amphetamine.

...

...

...

Level 3 prevention:

Treat mental and behavioural disorders due to use of amphetamines proactively.

Part 12

MENTAL AND BEHAVIOURAL DISORDERS DUE TO MULTIPLE DRUG USE

1. DEFINITION

Drugs encompass substances that affect the central nervous system, causing euphoria and mental and physical dependence.

Use of multiple drugs (at least 2 types of drugs) can lead to mental and behavioural disorders.

2. CAUSES

Easy and illegal synthesis of drugs.

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...

...

Some people (especially the youth) have a misguided notion that it is trendy to use drugs; persuade or force others to use drugs.

3. DIAGNOSIS

Common mental and behavioural disorders due to drug use include psychosis (e.g., delusions, hallucinations, aggression and violent acts) and affective disorders (e.g., anxiety, depression and mania).

3.1. Diagnostic criteria for multiple drug use

According to ICD 10 (1992), three or more of the following manifestations should have occurred together for at least one month or if persisting for periods of less than one month then they have occurred together repeatedly within a twelve-month period:

A strong desire or sense of compulsion to use drugs

Impaired capacity to control drug use in terms of onset, termination or level of use

A physiological withdrawal state when drug use is reduced or ceased

Evidence of tolerance to drug effects, such that there is a need for markedly increased amounts of drugs to achieve desired effect

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...

Persisting with drug use despite clear evidence of harmful consequences

However, drug dependence is sometimes difficult to diagnosed due to atypical withdrawal syndrome that may manifest only as physical and mental exhaustion.

3.2. Diagnostic criteria for mental disorders due to multiple drug use

Common diagnostic criteria for mental disorders due to multiple drug use

Onset of symptoms during or within two weeks of multiple drug use

Persistence of symptoms for more than 48 hours

Duration of the disorder not exceeding six months (if exceeding six months, residual and late-onset psychotic disorder due to multiple drug use (F19.7) should be considered).

Mental disorders due to multiple drug use can manifest as sleep disorders, anxiety disorders, depression, mania, delusions, hallucinations, aggression and violence.

3.2.1. Sleep disorders

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...

...

3.2.2. Anxiety disorders

The patient experiences fear and/or tremors and/or is concern about their physical and mental health.

3.2.3. Depressive disorder

There is/are low mood, decreased interest/attention, reduced energy, weakness, decreased activity. There is irritability or even suicide in some cases.

3.2.4. Hallucinations

The patient usually experiences diverse hallucinations, starting with false perceptions such as vivid colors or frightening or demonic surroundings.

Sounds become lively, causing the patient to think they are in a strange world, before turning into real hallucinations, usually auditory hallucinations i.e., voices of criticism, praise, disapproval or sometimes threats or condemnation towards the patient.

3.2.5. Delusions

At first, the patient feels doubt and, occasionally, perplexity accompanied by anxiety disorders or fear and eventually resulting in actual delusions.

...

...

...

3.2.6. Intermittent explosive disorder

Use of multiple drugs, including hallucinogens, can result in excitement, enhanced energy, increased motor activity, increased walking and, possibly, enhanced libido at first, and eventually lead to loss of control, disorientation, aggression (screaming, destroying, attacking other people, having no sense of self-preservation). This disorder is common in people intoxicated with hallucinogens or suffering from persecutory delusions.

Differential diagnosis:

Aggression in schizophrenia, manic episodes in bipolar affective disorder, etc.

Aggression in organic brain diseases such as brain tumors, encephalitis, temporal lobe epilepsy.

3.3. Paraclinical

- Multi drug 4 or 6 panel test for drugs

- Biochemical blood tests for drugs performed in qualified laboratories

- Complete blood count, performed daily in the first week if there is any abnormality or pre- and post-treatment

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...

...

- Basic coagulation test (performed every other day upon history or risk of hemorrhage)

- Tests for microorganisms: HIV, HbsAg, Anti HCV, syphilis.

- Urine analysis

- Chest X-ray

- Abdominal ultrasound

- Gastroscopy

- Psychological tests for determination of:

- Depression level (HDRS, Beck)

- Anxiety level (HARS, Zung)

...

...

...

- Personality characteristics (EPI, MMPI)

- Sleep disorder level (PSQI)

- The abovementioned psychological tests need to be performed pre- and post-treatment.

- Additional psychological tests include assessment of cognitive impairment (MMSE), stress-anxiety-depression disorders (DASS), etc.

- ECG

- EEG, cerebral blood flow, CT, MRI, etc.

- Paraclinical tests must be performed daily upon detection of abnormality.

- Paraclinical tests shall be performed based on specialized medical consultation upon detection of abnormality.

4. TREATMENT

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...

...

Maintain life functions such as by providing emergency care for other life-threatening internal medicine diseases. If the patient is being aggressive, inject antipsychotic drug(s).

When the patient is no longer in critical condition and develops mental disorders such as anxiety, fear, depression or psychosis (delusions/hallucinations), administer anti-anxiety drugs, antidepressants or antipsychotic drugs.

4.2. Treatment regimens

- Medicinal chemistry approaches

- Minor tranquillizers

- Antipsychotic drugs

- Antidepressants

- Psychotherapy: individual therapy, family therapy, etc.

4.3. Specific treatment: depending on each patient’s condition and clinical picture

...

...

...

Select one or two or three drug(s) from the following list (prioritize single-drug therapy; if poorly effective, consider switching to another drug or combining a maximum of 3 drugs to minimize undesired effects):

Typical (Classic) tranquilizers:

Haloperidol: 1,5mg tablet, 5 mg tablet, 5mg injection with a dose of 5-30mg/24 hours

Chlorpromazine: 25mg tablet, 25mg injection with a dose of 50-250mg/24 hours

Levomepromazine: 25mg tablet with a dose of 25-250mg/24 hours

Atypical (New) tranquilizers:

Amisulpride: 50mg/200mg/400mg tablet with a dose of 200-800mg/24 hours

Clozapine: 25mg/100mg tablet with a dose of 50-800mg/24 hours

Risperidone: 1mg/2mg tablet with a dose of 1-12mg/24 hours

...

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...

Quetiapine 50mg/200mg/300mg tablet with a dose of 600-800 mg/ day

Aripiprazole: 5mg/10mg/15mg/30mg tablet with a dose of 10-30mg/day

4.3.2. Antidepressants

Select one or two or three drug(s) from the following list (prioritize single-drug therapy; if poorly effective, consider switching to another drug or combining a maximum of 3 drugs to minimize undesired effects):

Selective serotonin reuptake inhibitors:

Fluoxetine 20mg with a dose of 10-40mg/day

Paroxetine 20mg with a dose of 20-60mg/day

Sertraline 50mg with a dose of 50-200mg/day

Fluvoxamine 100mg with a dose of 100-300mg/day

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Citalopram with a dose of 10-60mg/day

Dual-action drugs:

Venlafaxine 37,5mg with a dose of 75-225mg/day

Mirtazapine 30mg with a dose of 30-60mg/day

Tricyclic antidepressants:

Amitriptyline 25mg with a dose of 50-100mg/day

Clomipramine 25mg with a dose of 50-75mg/day

Imipramine with a dose of 10-150mg/day

Other types of antidepressants:

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4.3.4. Mood stabilizers

Select one or two drug(s) from the following list (prioritize single-drug therapy; if poorly effective, consider switching to another drug or combining a maximum of 2 drugs to minimize undesired effects):

Sodium valproate 200mg-2500mg/day

Divalproex sodium 750mg/day - 60mg/kg/day

Carbamazepine with a dose of 400-1200mg/day

Oxcarbazepine 1200 – 2400mg/day

Lamotrigine 100 – 400 mg/day

Topiramate: 50 – 400mg/day

Gabapentin: 300 – 1800mg/day

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Diazepam: 5 - 30mg/day

Lorazepam: 1 - 4mg/day

Clonazepam: 1 - 8mg/day

Bromazepam: 3 - 6mg/day

4.3.5. Other anti-anxiety drugs and sleeping pills: select one of the following: etifoxine, tofisopam, passiflora foetida, zopiclone, eszopiclone, melatonin

4.3.6. Other drugs: cerebral circulation boosters and neurological supplements (piracetam, citicoline, ginkgo biloba, vinpocetine, choline alfoscerate, cinnarizine, etc.), vitamins and micronutrients, antihistamines (hydroxyzine, etc.), beta blockers, etc.

Dietary supplements, parenteral nutrition

Hepatoprotective medications: aminoleban, silymarin, boganic, other branched-chain amino acids, etc.

Cognitive enhancers: physical rehabilitation, occupational therapy, etc.

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Treatment of associated physical diseases

Diet: nutritious, digestible and safe food from all 4 food groups

Community-based rehabilitation: occupational therapy

5. PROGNOSIS AND COMPLICATIONS

The prognosis is good if the patient is treated promptly. However, some cases can result in chronic psychosis, depression or dementia.

6. PREVENTION

Level 1 prevention:

Exercise state management of drugs in general and narcotic substances in particular.

Raise awareness of the harmful effects of narcotic substances to deter people from using them.

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Screen drug users to detect mental disorders early on.

Level 3 prevention:

Treat mental and behavioural disorders due to use of narcotic substances proactively. Provide addiction or harm reduction treatment.

Part 13

SCHIZOPHRENIA

1. DEFINITION

Schizophrenia is a type of progressive severe psychosis with a tendency to become chronic. The patient gradually withdraws from the outside world and into the self, becomes colder in terms of emotions, and suffers from impaired working or learning capacity and bizarre thoughts and behaviors.

Schizophrenia affects approximately 0,3-0,5% of the population with onset between 18-40 years of age.

2. CAUSES

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3. DIAGNOSIS

3.1. ICD-10 diagnostic criteria: there are 9 groups of symptoms:

1) Thought echo, thought insertion or withdrawal, and thought broadcasting.

2) Delusions of control, influence, or passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensations; delusional perception.

3) Hallucinatory voices giving a running commentary on the patient's behavior, or discussing the patient among themselves, or other types of hallucinatory voices coming from some part of the body.

4) Persistent delusions of other kinds that are culturally inappropriate and completely impossible, such as religious or political identity, or superhuman powers and abilities (e.g. being able to control the weather, or being in communication with aliens from another world);

5) Persistent hallucinations in any modality, when accompanied either by fleeting or half-formed delusions without clear affective content, or by persistent over-valued ideas, or when occurring every day for weeks or months on end.

6) Breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech, or neologisms.

7) Catatonic behavior, such as excitement, posturing, or waxy flexibility, negativism, mutism, and stupor.

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9) A significant and consistent change in the overall quality of some aspects of personal behavior, manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal.

There must be a minimum of one very clear symptom belonging to any one of the groups listed as 1) to 4) above, or symptoms from at least two of the groups referred to as 5) to 9).

The abovementioned symptoms should have been clearly present for most of the time during a period of 1 month or more.

The diagnosis of schizophrenia should not be made in the presence of extensive depressive or manic symptoms unless it is clear that schizophrenic symptoms antedated the affective disturbance.

Schizophrenia should not be diagnosed in the presence of overt brain disease or during states of drug intoxication.

3.2. Clinical forms of schizophrenia

According to ICD-10: paranoid schizophrenia; hebephrenic schizophrenia; catatonic schizophrenia; undifferentiated schizophrenia; post-schizophrenic depression; residual schizophrenia; simple schizophrenia.

3.3. Differential diagnosis

Organic psychosis: organic psychosis patients may exhibit symptoms similar to schizophrenia but fail to meet the diagnostic criteria for schizophrenia. Neurological and paraclinical examinations reveal signs of an overt organic disease.

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3.4. Paraclinical: providing support for diagnosis, monitoring and treatment

3.4.1. Basis laboratory tests

Blood tests: hematological tests, biochemical tests, tests for microorganisms (HIV, VGB, VGC)

Urine test, tests for narcotic substances, serological testing for syphilis, etc.

3.4.2. Medical imaging, functional diagnostics

Chest X-ray, abdominal ultrasound

EEG, ECG, cerebral blood flow, transcranial Doppler ultrasound, etc. Cranial CT scanner, cranial MRI, etc. if necessary.

3.4.3. Psychological tests

Assessment using the Positive and Negative Syndrome Scale (PANSS)

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4. TREATMENT

4.1. Treatment rules

Schizophrenia is an illness of unknown cause that requires early detection and intervention. Treatment mostly involves treatment of symptoms.

Medicinal chemistry approaches play an important role, especially for positive symptoms. Multiple therapies such as psychotherapy, occupational therapy and social readaptation should be given together, especially for negative symptoms.

Prioritize single-drug therapy; if the patient does not respond to the drug partially or completely, combine 2 different types of tranquilizers and avoid combining 3 or more tranquilizers.

Closely monitor medication use to promptly detect and handle side effects of tranquilizers.

Change the family and community’s attitude towards schizophrenia patients (avoid discriminating against these patients). The doctor, the family and the community shall closely cooperate in taking care of schizophrenia patients.

Promptly detect and handle factors inducing relapse.

Provide maintenance treatment after the first psychotic episode, and manage and monitor the patient to prevent relapse in the community.

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Medicinal chemistry approaches + Psychotherapy, community-based rehabilitation

4.2.1. Medicinal chemistry approaches: select one, two or three drugs from the following list:

Classic tranquilizers:

Chlorpromazine: 25mg tablet, 25mg injection with a dose of 50-250mg/24 hours

Levomepromazine: 25mg tablet with a dose of 25-250mg/24 hours

Haloperidol: 1,5mg tablet, 5 mg tablet, 5mg injection with a dose of 5-30mg/24 hours

Thioridazine: 50mg tablet with a dose of 100-300mg/day

Atypical (New) tranquilizers:

Amisulpride: 50mg/200mg/400mg tablet with a dose of 200-800mg/24 hours

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Risperidone: 1mg/2mg tablet with a dose of 1-12mg/24 hours

Olanzapine: 5mg/10mg tablet with a dose of 5-30mg/24 hours

Quetiapine 50mg/200mg/300mg tablet with a dose of 600-800 mg/ day

Aripiprazole: 5mg/10mg/15mg/30mg tablet with a dose of 10-15 mg/day (maximum 30mg/day)

Tranquilizers may be administered with higher dose depending on the patient’s condition and response.

Tranquilizers with prolonged effects: should be administered to patients not taking their medications daily. Before using a long-acting tranquilizer, administer an equivalent short-acting tranquilizer to test the patient’s response to the drug.

Haloperidol decanoate: 50mg/ml injection, administer 25-50mg by intramuscular injection every 4 weeks

Flupenthixol decanoate: 20mg/ml injection, administer 20-40mg by intramuscular injection every 2-4 weeks

Fluphenazine decanoate: 25mg/ml injection, administer 12,5-50mg by intramuscular injection every 3-4 weeks (maximum 100 mg/day)

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Drug combination therapy: incorporate the following drugs if necessary:

Minor tranquillizers and anti-anxiety drugs: benzodiazepines (diazepam, lorazepam, bromazepam, alprazolam, etc.) and non-benzodiazepines (etifoxine HCL, sedanxio, zopiclone, etc.)

Beta blockers: propanolol, etc.

Antidepressants: SSRI, TCA, SNRI, NaSSa, etc.

Mood stabilizers: sodium valproate, divalproex, carbamazepine, oxcarbazepine, etc.

Neuronal supplements: piracetam, ginkgo giloba, vinpocetine, choline alfoscerate, nicergoline, etc.

Diet: dietary supplements, vitamin and mineral supplements (B vitamins), parenteral nutrition, etc.

Liver supplements, cognitive enhancers, etc.

Treatment monitoring

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Extrapyramidal symptoms (acute dystonia, drug-induced anxiety, Parkinsonism): cholinesterase inhibitors (Trihexyphenidyl, Benztropine), beta blockers, minor tranquillizers. Neuroleptic malignant syndrome must be detected early on and monitored and treated in the intensive care unit.

Metabolic disorders must be monitored periodically (via BMI and biochemical tests every 3-6 months) and detected and treated promptly. Monitor white blood cell every 3 months in patients administered clozapine. Tardive dyskinesia: muscle relaxants, minor tranquillizers, vitamin E, anticholinergic drugs, etc.

4.2.2. Transcranial electrical stimulation and transcranial magnetic stimulation

Transcranial electrical stimulation is effective in some cases (catatonia, suicidal ideation and behaviors caused by depression, persecutory delusions and hallucinations, excitement, etc. that are poorly responsive to medications).

Transcranial magnetic stimulation is effective against persistent auditory hallucinations, etc.

4.2.3. Psychotherapy

Among different types of psychotherapy (individual therapy, family therapy, group therapy, etc.), behavioral therapy is of importance to schizophrenia patients. Support groups should be created to provide assistance for schizophrenia patients and their families.

4.2.4. Occupational therapy and rehabilitation

The principle is to let the patient function within their current capacity to rebuild trust.

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Pay attention to the patient’s socio-economic-cultural environment when providing occupational rehabilitation.

4.2.5. Physical rehabilitation, occupational therapy, and management, treatment and monitoring in the community

5. PROGNOSIS AND COMPLICATIONS

The later the illness starts, the milder it is.

Illness course: episodic with stable deficit course has better prognosis than continuous or episodic with progressive deficit course

Pre-illness personality: patients with an outgoing personality pre-schizophrenia have better prognosis than those with a reserved personality.

Prognosis is better if external causes are present.

Prognosis is better if few genetic factors are involved.

Patients without or with few negative symptoms have better prognosis.

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As the cause of schizophrenia is unknown, there is no definite preventive measure.

Teach children to socialize and adapt to challenging conditions and environments.

Monitor persons with a family history of schizophrenia (parents, grandparents, siblings, close relatives) to detect and treat the illness early on.

Educate patients and their families on the illness and factors inducing relapse for them to cooperate in and follow the treatment regimen.

Continue to monitor the patient after discharge, persist in maintenance treatment, detect risk factors and proactively treat infections, physical diseases, etc. to prevent relapse.

Part 14

SCHIZOTYPAL DISORDER

1. DEFINITION

Schizotypal disorder is a gradually progressive disorder with a tendency to become chronic. It is characterized by eccentric behavior and anomalies of thinking and affect which resemble those seen in schizophrenia, though no definite and characteristic schizophrenic anomalies occur at any stage.

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Primary and secondary causes of schizotypal disorder are still unknown. Schizotypal disorder is classified as an endogenous illness that involves multiple factors such as heredity, immunity, intoxication, etc. Two areas that have garnered most attention are genetic abnormalities and neurotransmitter abnormalities.

3. DIAGNOSIS

3.1. ICD-10 diagnostic criteria: there are 9 groups of symptoms:

1) Inappropriate or constricted affect (the individual appears cold and aloof)

2) Behavior or appearance that is odd, eccentric, or peculiar

3) Poor rapport with others and a tendency to social withdrawal

4) Odd beliefs or magical thinking, influencing behavior and inconsistent with subcultural norms

5) Suspiciousness or paranoid ideas

6) Obsessive ruminations without inner resistance, often with dysmorphophobic, sexual or aggressive contents

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8) Vague, circumstantial, metaphorical, over elaborate, or stereotyped thinking, manifested by odd speech or in other ways, without gross incoherence

9) Occasional transient quasi-psychotic episodes with intense illusions, auditory or other hallucinations, and delusion-like ideas, usually occurring without external provocation

At least 4 of the groups listed above must be present.

The abovementioned symptoms should have been clearly present for at least 2 years or appeared in a continuous or recurrent manner.

The patient has never met the criteria for any disorder under F20- (Schizophrenia).

Clinical forms of schizotypal disorder

Borderline schizophrenia

Latent schizophrenia

Prepsychotic schizophrenia

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Pseudopsychopathic schizophrenia

Schizotypal personality disorder

3.2. Differential diagnosis

Simple schizophrenia

Simple schizophrenia is a disorder in which the characteristic "negative" features of schizophrenia develop without being preceded by any overt psychotic symptoms.

Schizotypal personality disorder

3.3. Paraclinical: providing support for diagnosis, monitoring and treatment

3.3.1. Basis laboratory tests

Blood tests: hematological tests, biochemical tests, tests for microorganisms (HIV, VGB, VGC), etc.

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3.3.2. Medical imaging, functional diagnostics

Chest X-ray, abdominal ultrasound

EEG, ECG, cerebral blood flow, transcranial Doppler ultrasound, etc. Cranial CT scanner, cranial MRI, etc. if necessary.

3.3.3. Psychological tests

Assessment using the Positive and Negative Syndrome Scale (PANSS)

Personality tests: EPI, MMPI, other psychological tests such as BDI, Zung, HDRS, HARS, HAD, MMSE, etc.

4. TREATMENT

4.1. Treatment rules

Schizotypal disorder is an illness of unknown cause that requires early detection and intervention. Treatment mostly involves treatment of symptoms.

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Prioritize single-drug therapy; if the patient does not respond to the drug partially or completely, combine 2 different types of tranquilizers and avoid combining 3 or more tranquilizers.

Closely monitor the treatment process to promptly detect and handle side effects of tranquilizers.

Treat patients in acute stage in specialized establishments, provide maintenance treatment, prevent relapse in the community and provide rehabilitation for patients.

Change the family and community’s attitude towards schizotypal disorder patients (avoid isolating or discriminating against these patients). The doctor, the family and the community shall closely cooperate in taking care of schizotypal disorder patients.

Promptly detect and handle factors inducing relapse.

4.2. Treatment regimens: medicinal chemistry approaches + psychotherapy, rehabilitation

4.2.1. Medicinal chemistry approaches: select one, two or three drugs from the following list:

Classic tranquilizers:

Chlorpromazine: 25mg tablet, 25mg injection with a dose of 50-250mg/24 hours

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...

...

Haloperidol: 1,5mg tablet, 5 mg tablet, 5mg injection with a dose of 5-30mg/24 hours

Thioridazine: 50mg tablet with a dose of 100-300mg/day

Atypical (New) tranquilizers:

Amisulpride: 50mg/200mg/400mg tablet with a dose of 200-800mg/24 hours

Clozapine: 25mg/100mg tablet with a dose of 50-800mg/24 hours

Risperidone: 1mg/2mg tablet with a dose of 1-12mg/24 hours

Olanzapine: 5mg/10mg tablet with a dose of 5-30mg/24 hours

Quetiapine 50mg/200mg/300mg tablet with a dose of 600-800 mg/ day

Aripiprazole: 5mg/10mg/15mg/30mg tablet with a dose of 10-15 mg/day (maximum 30mg/day)

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Tranquilizers with prolonged effects: should be administered to patients not taking their medications daily. Before using a long-acting tranquilizer, administer an equivalent short-acting tranquilizer to test the patient’s response to the drug.

Haloperidol decanoate: 50mg/ml injection, administer 25-50mg by intramuscular injection every 4 weeks

Flupenthixol decanoate: 20mg/ml injection, administer 20-40mg by intramuscular injection every 2-4 weeks

Fluphenazine decanoate: 25mg/ml injection, administer 12,5-50mg by intramuscular injection every 3-4 weeks (maximum 100 mg/day)

Aripiprazole: 300mg or 400mg injection every 4 weeks

Drug combination therapy: incorporate the following drugs if necessary:

Minor tranquillizers and anti-anxiety drugs: benzodiazepines (diazepam, lorazepam, bromazepam, alprazolam, etc.) and non-benzodiazepines (etifoxine HCL, sedanxio, zopiclone, etc.)

Beta blockers: propanolol, etc.

Antidepressants: SSRI, TCA, SNRI, NaSSa, etc.

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Liver supplements, cognitive enhancers, etc.

Neuronal supplements: piracetam, ginkgo giloba, vinpocetine, choline alfoscerate, nicergoline, etc.

Treatment monitoring

Side effects of tranquilizers must be handled immediately upon appearance.

Extrapyramidal symptoms (acute dystonia, drug-induced anxiety, Parkinsonism): cholinesterase inhibitors (Trihexyphenidyl, Benztropine), beta blockers, minor tranquillizers. Neuroleptic malignant syndrome must be detected early on and monitored and treated in the intensive care unit.

Metabolic disorders must be monitored periodically (via BMI and biochemical tests every 3-6 months) and detected and treated promptly. Monitor white blood cell every 3 months in patients administered clozapine. Tardive dyskinesia: muscle relaxants, minor tranquillizers, vitamin E, anticholinergic drugs, etc.

4.2.2. Psychotherapy

There are different types of psychotherapy available such as individual therapy, family therapy, group therapy, etc. Support groups should be created to provide assistance for the patients and their families.

4.2.3. Occupational therapy and rehabilitation

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Gradually raise the level of functioning to the highest at which the patient does not feel pressured.

Pay attention to the patient’s socio-economic-cultural environment when providing occupational rehabilitation.

4.2.4. Physical rehabilitation, occupational therapy, and management, treatment and monitoring in the community

5. PROGNOSIS AND COMPLICATIONS

The following factors can influence a patient’s prognosis:

The later the illness starts, the milder it is.

Pre-illness personality: patients with an outgoing personality pre-schizophrenia have better prognosis than those with a reserved personality.

Prognosis is better if external causes are present.

Prognosis is poorer if many genetic factors are involved.

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6. PREVENTION

As the cause of schizotypal disorder is unknown, there is no definite preventive measure.

Teach children to socialize and adapt to challenging conditions and environments.

Monitor persons with a family history of schizophrenia/schizotypal disorder (parents, grandparents, siblings, close relatives) to detect and treat the illness early on.

Continue to monitor the patient after discharge, persist in maintenance treatment, detect risk factors and proactively treat infections, physical diseases, etc. to prevent relapse.

Part 15

PERSISTENT DELUSIONAL DISORDERS

1. DEFINITION

Persistent delusional disorders are mental disorders on the schizophrenia spectrum that are characterized by the development either of a single delusion or of a set of related delusions which are usually persistent and sometimes lifelong. The delusions often are persecutory, hypochondriacal, or grandiose, or concern litigation or jealousy. Depressive episodes and/or hallucinations might be present.

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2. CAUSES

The causes of these disorders are unknown but genetic factors, personality characteristics, life circumstances, etc. are related to the genesis.

3. DIAGNOSIS

3.1. ICD 10 diagnostic criteria

This group of disorders is characterized by the development either of a single delusion or of a set of related delusions. The delusions are highly variable in content. Often they are persecutory, hypochondriacal, or grandiose, or concern litigation or jealousy, etc.

The symptoms must persist for at least 3 months.

The patient does not meet all criteria for schizophrenia.

There must be no persistent hallucinations (or only occasional auditory hallucinations without third-person voices or continuous commentary).

Depressive symptoms may be present intermittently, provided that the delusions persist at times when there is no disturbance of mood.

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Clinical forms

- Delusional disorder (F22.0)

- Other persistent delusional disorders (F22.8)

- Persistent delusional disorder, unspecified (F22.9)

3.2. Differential diagnosis

- Organic psychosis

- Paranoid personality disorder

- Temporary paranoid reactions

- Paranoid schizophrenia

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3.3. Paraclinical

3.3.1. Basic laboratory tests

Blood tests: hematological tests, biochemical tests, tests for microorganisms (HIV, VGB, VGC)

Urine test, tests for narcotic substances, serological testing for syphilis, etc.

3.3.2. Medical imaging, functional diagnostics

Chest X-ray, abdominal ultrasound

EEG, ECG, cerebral blood flow, transcranial Doppler ultrasound, etc. Cranial CT scanner, cranial MRI, etc. if necessary.

3.3.3. Psychological tests

Assessment using the Positive and Negative Syndrome Scale (PANSS)

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4. TREATMENT

4.1. Treatment rules

As patients with persistent delusional disorders always deny being ill and refuse to be hospitalized, treatment usually involves enforced and long-term treatment, mainly medicinal chemistry approaches, and early detection and intervention.

Prioritize single-drug therapy; if the patient does not respond to the drug partially or completely, combine 2 different types of tranquilizers and avoid combining 3 or more tranquilizers.

Closely monitor medication use to promptly detect and handle side effects of tranquilizers.

Ensure the patient take their medications to keep the manifestations of affect and behavioural disorders at an acceptable level.

Promptly detect and handle factors inducing relapse.

Provide maintenance treatment after the first psychotic episode, and manage and monitor the patient to prevent relapse in the community. Incorporate psychotherapy into the treatment regimen.

4.2. Treatment regimens: medicinal chemistry approaches + psychotherapy

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Classic tranquilizers:

Chlorpromazine: 25mg tablet, 25mg injection with a dose of 50-250mg/24 hours

Levomepromazine: 25mg tablet with a dose of 25-250mg/24 hours

Haloperidol: 1,5mg tablet, 5 mg tablet, 5mg injection with a dose of 5-30mg/24 hours

Thioridazine: 50mg tablet with a dose of 100-300mg/day

Atypical (New) tranquilizers:

Amisulpride: 50mg/200mg/400mg tablet with a dose of 200-800mg/24 hours

Clozapine: 25mg/100mg tablet with a dose of 50-800mg/24 hours

Risperidone: 1mg/2mg tablet with a dose of 1-12mg/24 hours

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...

Quetiapine 50mg/200mg/300mg tablet with a dose of 600-800 mg/ day

Aripiprazole: 5mg/10mg/15mg/30mg tablet with a dose of 10-15 mg/day (maximum 30mg/day)

Tranquilizers may be administered with higher dose depending on the patient’s condition and response.

Tranquilizers with prolonged effects: should be administered to patients not taking their medications daily. Before using a long-acting tranquilizer, administer an equivalent short-acting tranquilizer to test the patient’s response to the drug.

Haloperidol decanoate: 50mg/ml injection, administer 25-50mg by intramuscular injection every 4 weeks

Flupenthixol decanoate: 20mg/ml injection, administer 20-40mg by intramuscular injection every 2-4 weeks

Fluphenazine decanoate: 25mg/ml injection, administer 12,5-50mg by intramuscular injection every 3-4 weeks (maximum 100 mg/day)

Aripiprazole: 300mg or 400mg injection every 4 weeks

Drug combination therapy: incorporate the following drugs if necessary:

...

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...

Beta blockers: propanolol, etc.

Antidepressants: SSRI, TCA, SNRI, NaSSa, etc.

Mood stabilizers: sodium valproate, divalproex, carbamazepine, oxcarbazepine, etc.

Diet: dietary supplements, vitamin and mineral supplements (B vitamins), parenteral nutrition, etc.

Neuronal supplements: piracetam, ginkgo giloba, vinpocetine, choline alfoscerate, nicergoline, etc.

Liver supplements, cognitive enhancers, etc.

Treatment monitoring

Promptly detect and handle the following side effects:

Extrapyramidal symptoms (acute dystonia, drug-induced anxiety, Parkinsonism): cholinesterase inhibitors (Trihexyphenidyl, Benztropine), beta blockers, minor tranquillizers. Neuroleptic malignant syndrome must be detected early on and monitored and treated in the intensive care unit.

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4.2.2. Psychotherapy

Provide different types of psychotherapies and individual therapy to help the patient understand their illness.

Provide family therapy, group therapy, music therapy, etc. to help the patient rejoin the community.

4.2.3. Occupational therapy and rehabilitation

The principle is to let the patient function within their current capacity to rebuild trust.

Gradually raise the level of functioning to the highest at which the patient does not feel pressured.

Pay attention to the patient’s socio-economic-cultural environment when providing occupational rehabilitation.

4.2.4. Physical rehabilitation, occupational therapy, and management and provision of treatment and maintenance treatment to prevent relapse in the community

5. PROGNOSIS AND COMPLICATIONS

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6. PREVENTION

As the exact cause is still unknown, prevention involves:

Learn how to be independent and adapt to challenging conditions and environments.

Avoid stress in daily life, learn how to share and destress.

Monitor persons with a family history of schizophrenia/schizotypal disorder/delusional disorder (parents, grandparents, siblings, close relatives) to detect and treat the illness early on.

Continue to monitor the patient after discharge, provide maintenance treatment and monitor the illness in specialized departments and in the community. Avoid letting the patient overwork or feel stressed and treat physical diseases (if any) proactively to prevent relapse.

Part 16

ACUTE AND TRANSIENT PSYCHOTIC DISORDERS

1. DEFINITION

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2. CAUSES

2.1. Familial factors: studies show that 20-30% of patients have a family history of mental disorders such as schizophrenia, mood disorders (depression, bipolar affective disorder), acute psychosis, etc.

2.2. Role of stress: some studies indicate that 20-30% of patients have experienced a stressful event such as bereavement, unexpected loss of property, partner or marriage, etc.

2.3. Role of personality: patients have some abnormal personality traits i.e. sensitivity, vulnerability, schizotypal personality traits (reserved, social withdrawal, etc.)

3. DIAGNOSIS: ICD 10 diagnostic criteria:

3.1. Diagnostic criteria for acute and transient psychotic disorders:

An acute psychotic episode with onset within 2 weeks and lasting for a month; clinical manifestations of psychosis such as hallucinations, delusions, behavioral and mood disorders and affected socio-professional relationships.

Symptoms of any mood disorder during the psychotic episode fail to meet the diagnostic criteria for manic or depressive episode. The abovementioned mental state is not historically associated with a physical disease or alcohol or drug use.

3.2. ICD – 10 clinical forms:

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(F23.0): the onset must be acute and take place within 2 weeks or less.

Psychotic symptoms such as hallucinations and delusions change in terms of contents and intensity frequently or even from hour to hour. Mood disorders also vary continuously, depending on contents of the psychotic symptoms.

Clinical picture does not fulfill the diagnostic criteria for schizophrenia or mood disorders.

Acute polymorphic psychotic disorder with symptoms of schizophrenia (F23.1): acute onset happens within 2 weeks or less.

Hallucinations and delusions change in terms of contents and intensity from day to day. Mood disorders  vary depending on the psychotic symptoms

Clinical manifestations meet the diagnostic criteria for schizophrenia.

Acute schizophrenia-like psychotic disorder (F23.2)

Acute onset happens within 2 weeks or less.

Psychotic symptoms (i.e., hallucinations, delusions) are comparatively stable and fulfill the criteria for schizophrenia.

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Other acute predominantly delusional psychotic disorders (F23.3)

Acute onset happens within 2 weeks or less.

Delusions are comparatively stable.

Clinical picture does not fulfill the diagnostic criteria for schizophrenia and other acute polymorphic psychotic disorders.

Other acute and transient psychotic disorders (F23.8): Any other acute psychotic disorders that are unclassifiable under any other category in F23 are coded here.

Acute and transient psychotic disorder, unspecified (F23.9): includes (brief) reactive psychosis NOS.

3.3. Differential diagnosis

Organic psychosis

The patient has psychotic symptoms due to the impact of cerebral or non-cerebral causes on cerebral functions. Symptoms similar to those of schizophrenic disorders do not fulfill the diagnostic criteria. Signs of an organic disease is detected upon clinical and paraclinical neurological examination.

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A psychotic state (hallucinations, delusion, etc.) appears during or immediately after use of psychoactive substances, or after cessation of use of psychoactive substances (withdrawal syndrome). Clinical examination and medical history reveal an association with use of psychoactive substances. Laboratory tests indicate intoxication/drug, alcohol or narcotic substance use.

Schizophrenia:

Schizophrenia develops more slowly with onset lasting for months sometimes and precursory or bizarre delusions. These delusions usually appear continuously with consistent contents and intensity. Delusional perception and negative symptoms may be present. The abovementioned symptoms should have been clearly present for most of the time during a period of 1 month.

Persistent delusional disorders: systematic delusions persist for at least 3 months.

Mood disorders:..

3.3. Paraclinical: providing support for diagnosis, monitoring and treatment

3.3.1. Basic laboratory tests

Blood tests: hematological tests, biochemical tests, tests for microorganisms (HIV, VGB, VGC)

Urine test, tests for narcotic substances, serological testing for syphilis, etc.

...

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...

Chest X-ray, abdominal ultrasound

EEG, ECG, cerebral blood flow, transcranial Doppler ultrasound, etc. Cranial CT scanner, cranial MRI, etc. if necessary.

3.3.3. Psychological tests

Assessment using the Positive and Negative Syndrome Scale (PANSS)

Personality tests: EPI, MMPI, other psychological tests such as BDI, Zung, HDRS, HARS, HAD, MMSE, etc.

4. TREATMENT

4.1. Treatment rules

Acute and transient psychotic disorders have multiple causes, among which, a combination of biological and socio-psychological factors is of importance. Treatment of these disorders must focus on medicinal chemistry approaches and psychotherapy.

Medicinal chemistry approaches play an important role, especially for positive symptoms. Multiple therapies such as psychotherapy, occupational therapy and social readaptation should be given together, especially for negative symptoms.

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Closely monitor medication use to promptly detect and handle side effects of tranquilizers.

Change the family and community’s attitude towards patients with acute and transient psychotic disorders (avoid isolating or discriminating against these patients). The doctor, the family and the community shall closely cooperate in taking care of these patients.

Promptly detect and handle factors inducing relapse. Give maintenance treatment after the first psychotic episode, and manage and monitor the patient to prevent relapse.

4.2. Treatment regimens: medicinal chemistry approaches + psychotherapy

4.2.1. Medicinal chemistry approaches: select one, two or three drugs from the following list:

Classic tranquilizers:

Chlorpromazine: 25mg tablet, 25mg injection with a dose of 50-250mg/24 hours

Levomepromazine: 25mg tablet with a dose of 25-250mg/24 hours

Haloperidol: 1,5mg tablet, 5 mg tablet, 5mg injection with a dose of 5-30mg/24 hours

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Atypical (New) tranquilizers:

Amisulpride: 50mg/200mg/400mg tablet with a dose of 200-800mg/24 hours

Clozapine: 25mg/100mg tablet with a dose of 50-800mg/24 hours

Risperidone: 1mg/2mg tablet with a dose of 1-12mg/24 hours

Olanzapine: 5mg/10mg tablet with a dose of 5-30mg/24 hours

Quetiapine 50mg/200mg/300mg tablet with a dose of 600-800 mg/ day

Aripiprazole: 5mg/10mg/15mg/30mg tablet with a dose of 10-15 mg/day (maximum 30mg/day)

Tranquilizers may be administered with higher dose depending on the patient’s condition and response.

Tranquilizers with prolonged effects: should be administered to patients not taking their medications daily. Before using a long-acting tranquilizer, administer an equivalent short-acting tranquilizer to test the patient’s response to the drug.

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Flupenthixol decanoate: 20mg/ml injection, administer 20-40mg by intramuscular injection every 2-4 weeks

Fluphenazine decanoate: 25mg/ml injection, administer 12,5-50mg by intramuscular injection every 3-4 weeks (maximum 100 mg/day)

Aripiprazole: 300mg or 400mg injection every 4 weeks

Drug combination therapy: incorporate the following drug groups if necessary:

Minor tranquillizers and anti-anxiety drugs: benzodiazepines (diazepam, lorazepam, bromazepam, alprazolam, etc.) and non-benzodiazepines (etifoxine HCL, sedanxio, zopiclone, etc.)

Beta blockers: propanolol, etc.

Antidepressants: SSRI, TCA, SNRI, NaSSa, etc.

Mood stabilizers: sodium valproate, divalproex, carbamazepine, oxcarbazepine, etc.

Diet: dietary supplements, vitamin and mineral supplements (B vitamins), parenteral nutrition, etc.

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Liver supplements, cognitive enhancers, etc.

Treatment monitoring

Promptly detect and handle the following side effects:

Extrapyramidal symptoms (acute dystonia, drug-induced anxiety, Parkinsonism): cholinesterase inhibitors (Trihexyphenidyl, Benztropine), beta blockers, minor tranquillizers. Neuroleptic malignant syndrome must be detected early on and monitored and treated in the intensive care unit.

Metabolic disorders must be monitored periodically (via BMI and biochemical tests every 3-6 months) and detected and treated promptly. Monitor white blood cell every 3 months in patients administered clozapine. Tardive dyskinesia: muscle relaxants, minor tranquillizers, vitamin E, anticholinergic drugs, etc.

4.2.2. Transcranial electrical stimulation and transcranial magnetic stimulation

Transcranial electrical stimulation is effective in some cases (catatonia, suicidal ideation and behaviors caused by persecutory delusions and hallucinations, excitement, etc. that do not respond to medications).

Transcranial magnetic stimulation is effective against persistent auditory hallucinations, etc.

4.2.3. Psychotherapy

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4.2.4. Occupational therapy and rehabilitation

4.2.5. Physical rehabilitation, occupational therapy, and maintenance treatment to prevent relapse in the community

5. PROGNOSIS AND COMPLICATIONS

Prognosis is relatively good if:

The patient is outgoing.

There is influence from external elements.

There is little influence from genetic factors.

Prognosis is relatively worse if:

The disorder has early onset.

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After the abovementioned psychotic episode, most patients fully recover without any personality change, and only a few may develop schizophrenia, persistent delusional disorders, mood disorders, etc.

6. PREVENTION

As the exact cause is still unknown, prevention involves:

Learn how to be independent and adapt to challenging conditions and environments.

Avoid stress in daily life, learn how to share and destress.

Monitor persons with a family history of schizophrenic disorders (parents, grandparents, siblings, close relatives) to detect and treat the illness early on.

Continue to monitor the patient after discharge, provide maintenance treatment and monitor the illness in specialized departments. Avoid letting the patient overwork or feel stressed and treat physical diseases (if any) proactively to prevent relapse.

Part 17

SCHIZOAFFECTIVE DISORDERS

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Schizoaffective disorders are episodic disorders in which both affective (mania/depression) and schizophrenic symptoms are prominent within the same episode of illness, preferably simultaneously, but at least within a few days of each other. These disorders tend to become chronic.

2. CAUSES

Primary and secondary causes of schizoaffective disorders are still unknown. Schizoaffective disorders are classified as endogenous illnesses that involve multiple factors such as heredity, immunity, intoxication, etc.

3. DIAGNOSIS

3.1. Diagnostic criteria for schizoaffective disorders

Schizoaffective disorders fulfill all criteria for moderate or severe mood disorders (F30, F31, F32).

Symptom belonging to at least one of the following groups should have been clearly present for at least 2 weeks:

(1). Thought echo, thought insertion or withdrawal, and thought broadcasting.

(2). Delusions of control, influence, or passivity.

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(4). Persistent delusions of other kinds that are culturally inappropriate or completely impossible.

(5). Inappropriate or irrelevant speech, or neologisms.

(6). Frequent or occasional catatonic behaviors, such as posturing, or waxy flexibility, negativism.

There must be no evidence of any organic mental disorder or psychosis induced by a psychoactive substance.

3.2. ICD – 10 clinical forms: Schizoaffective disorder, manic type

A. General criteria for schizoaffective disorders should have been fulfilled.

B. Criteria for a manic episode (F30.1 or F31.1) should have been fulfilled.

Schizoaffective disorder, depressive type

A. General criteria for schizoaffective disorders should have been fulfilled.

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Schizoaffective disorder, mixed type

A. General criteria for schizoaffective disorders should have been fulfilled.

B. Criteria for bipolar affective disorder, current episode mixed (F31.6) should have been fulfilled.

Other schizoaffective disorders and schizoaffective disorder, unspecified

3.3. Differential diagnosis

Schizophrenia: the patient develops psychotic symptoms such as delusions and hallucinations typical of schizophrenia without any typical affective symptom (mania/depression) in the same episode of illness.

Bipolar affective disorder with psychotic symptoms: the patient develops typical affective symptoms (depression/mania) without any psychotic symptom (delusions/hallucinations) typical of schizophrenia.

3.4. Paraclinical: providing support for diagnosis, monitoring and treatment

3.4.1. Basic laboratory tests

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Urine test, tests for narcotic substances, serological testing for syphilis, etc.

3.4.2. Medical imaging, functional diagnostics

Chest X-ray, abdominal ultrasound

EEG, ECG, cerebral blood flow, transcranial Doppler ultrasound, etc. Thyroid ultrasound, cranial CT scanner, cranial MRI, etc. if necessary.

3.4.3. Psychological tests

Assessment using the Positive and Negative Syndrome Scale (PANSS)

Personality tests: EPI, MMPI, other psychological tests such as BDI, Zung, HDRS, HARS, HAD, MMSE, Young, MDQ, etc.

4. TREATMENT

4.1. Treatment rules

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Medicinal chemistry approaches play an important role. Multiple therapies such as psychotherapy, occupational therapy and social readaptation should be given together.

Prioritize single-drug therapy; if the patient does not respond to the drug partially or completely, combine multiple drugs.

Closely monitor medication use to promptly detect and handle side effects.

Change the family and community’s attitude towards patients with schizoaffective disorders (avoid isolating or discriminating against these patients). The doctor, the family and the community shall closely cooperate in taking care of these patients.

Promptly detect and handle factors inducing relapse.

Provide maintenance treatment after the acute period, and manage and monitor the patient to prevent relapse in the community.

4.2. Treatment regimens: medicinal chemistry approaches + psychotherapy

4.2.1. Medicinal chemistry approaches

Tranquilizers: select one, two or three drug(s) from the following list:

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Chlorpromazine: 25mg tablet, 25mg injection with a dose of 50-250mg/24 hours

Levomepromazine: 25mg tablet with a dose of 25-250mg/24 hours

Haloperidol: 1,5mg tablet, 5 mg tablet, 5mg injection with a dose of 5-30mg/24 hours

Thioridazine: 50mg tablet with a dose of 100-300mg/day

Atypical (New) tranquilizers:

Amisulpride: 50mg/200mg/400mg tablet with a dose of 200-800mg/24 hours

Clozapine: 25mg/100mg tablet with a dose of 50-800mg/24 hours

Risperidone: 1mg/2mg tablet with a dose of 1-12mg/24 hours

Olanzapine: 5mg/10mg tablet with a dose of 5-30mg/24 hours

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Aripiprazole: 5mg/10mg/15mg/30mg tablet with a dose of 10-15 mg/day (maximum 30mg/day)

Tranquilizers may be administered with higher dose depending on the patient’s condition and response.

Antidepressants: select one, two or three drugs from the following list:

Selective serotonin reuptake inhibitors:

Fluoxetine 20mg with a dose of 10-40mg/day

Paroxetine 20mg with a dose of 20-60mg/day

Sertraline 50mg with a dose of 50-200mg/day

Fluvoxamine 100mg with a dose of 100-300mg/day

Escitalopram 10/20 mg with a dose of 10-20mg/day

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Dual-action drugs:

Venlafaxine 37,5mg with a dose of 75-225mg/day

Mirtazapine 30mg with a dose of 30-60mg/day

Tricyclic antidepressants:

Amitriptyline 25mg with a dose of 50-100mg/day

Clomipramine 25mg with a dose of 50-75mg/day

Imipramine with a dose of 10-150mg/day

Other types of antidepressants:

Tianeptine with a dose of 12,5 -50mg/day

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Mood stabilizers: select one drug from the following list:

Sodium valproate with a dose of 1200-1500mg/day and maximum dose of 60mg/kg/day

Divalproex sodium with a dose of 750mg/day - 60mg/kg/day

Carbamazepine with a dose of 400-1200mg/day

Oxcarbazepine with a dose of 1200 - 2400mg/day

Topiramate with a dose of 50-400mg/day

Lamotrigine with a dose of 100 - 400mg/day, etc.

a. Treatment of schizoaffective disorder, depressive type:

Incorporate tranquilizers and antidepressants.

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Minor tranquillizers and anti-anxiety drugs: benzodiazepines (diazepam, lorazepam, bromazepam, alprazolam, etc.) and non-benzodiazepines (etifoxine HCL, sedanxio, zopiclone, etc.); beta blockers: propanolol, etc.

Mood stabilizers: valproate, divalproex, lamotrigine, etc.

Diet: dietary supplements, B vitamins and mineral supplements, parenteral nutrition, etc.

Neuronal supplements: piracetam, ginkgo giloba, vinpocetine, choline alfoscerate, nicergoline, etc.

Liver supplements, cognitive enhancers, etc.

b. Treatment of schizoaffective disorder, manic type:

Incorporate tranquilizers and mood stabilizers.

Depending on each case, incorporate the following drug groups:

Minor tranquillizers and anti-anxiety drugs: benzodiazepines (diazepam, lorazepam, bromazepam, alprazolam, etc.) and non-benzodiazepines (etifoxine HCL, sedanxio, zopiclone, etc.); beta blockers: propanolol, etc.

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Liver supplements, cognitive enhancers, etc.

Diet: dietary supplements, B vitamins and mineral supplements, parenteral nutrition, etc.

c. Treatment of schizoaffective disorder, mixed type

Incorporate tranquilizers and mood stabilizers.

Depending on each case, incorporate the following drug groups:

Minor tranquillizers and anti-anxiety drugs: benzodiazepines (diazepam, lorazepam, bromazepam, alprazolam, etc.) and non-benzodiazepines (etifoxine HCL, sedanxio, zopiclone, etc.); beta blockers: propanolol, etc.

Antidepressants: SSRI, SSNI, mirtazapine, etc.

Neuronal supplements: piracetam, ginkgo giloba, vinpocetine, choline alfoscerate, nicergoline, etc.

Liver supplements, cognitive enhancers, etc.

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d. Treatment monitoring

Side effects of tranquilizers must be handled immediately upon appearance. Extrapyramidal symptoms (acute dystonia, drug-induced anxiety, Parkinsonism): cholinesterase inhibitors (Trihexyphenidyl, Benztropine), beta blockers, minor tranquillizers. Neuroleptic malignant syndrome and serotonin syndrome must be detected early on and monitored and treated in the intensive care unit. Metabolic disorders must be monitored periodically (via BMI and biochemical tests every 3-6 months) and detected and treated promptly. Monitor white blood cell every 3 months in patients administered clozapine. Tardive dyskinesia: muscle relaxants, minor tranquillizers, vitamin E, anticholinergic drugs, etc

4.2.2. Psychotherapy

A doctor - patient – family relationship should be established to support the patient through their psychological crisis. Individual therapy can help the patient understand their illness. Family therapy can help the patient reintegrate into their community.

4.2.3. Transcranial electrical stimulation and transcranial magnetic stimulation

Transcranial electrical stimulation is effective in some cases (catatonia, suicidal ideation and behaviors caused by depression, persecutory delusions and hallucinations, excitement, etc. that are poorly responsive to medications). Transcranial magnetic stimulation is effective against persistent auditory hallucinations, depressive disorders, etc.

4.2.4. Occupational therapy and rehabilitation

4.2.5. Physical rehabilitation, occupational therapy, and maintenance treatment to prevent relapse in the community

5. PROGNOSIS AND COMPLICATIONS

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Suicide is a life-threatening complication in patients with schizoaffective disorders.

6. PREVENTION: As the exact cause is still unknown, prevention involves:

Learn how to be independent and adapt to challenging conditions and environments.

Avoid stress, learn how to share and destress.

Monitor persons with a family history of endogenous mental disorders (parents, grandparents, siblings, close relatives) for early detection and treatment.